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Serum T3, T4, thyroid resin uptake, and FT4 are usually all increased Sometimes the T4 level may be normal but the serum T3 is elevated Serum T3 can be misleadingly elevated when blood is collected in tubes using a gel barrier, which causes certain immunoassays (eg, Immulite but not Axsym analyzers) to report serum total T3 levels that are falsely elevated in 24% of normal patients Serum T4 or T3 can be elevated in other nonthyroidal conditions Serum TSH is suppressed in hyperthyroidism, except in the very rare cases of pituitary inappropriate secretion of thyrotropin Serum TSH may be misleadingly low in other nonthyroidal conditions Hyperthyroidism can cause other laboratory abnormalities, including hypercalcemia, increased alkaline phosphatase, anemia, and decreased granulocytes Hypokalemia and hypophosphatemia occur in thyrotoxic periodic paralysis Problems of diagnosis occur in patients with acute psychiatric disorders; about 30% of these patients have hyperthyroxinemia without thyrotoxicosis The TSH is not usually suppressed, distinguishing psychiatric disorder from true hyperthyroidism T4 levels return to normal gradually In Graves disease, TSH-R Ab[stim] levels are usually high (65%) Antithyroglobulin or antithyroperoxidase antibodies are usually elevated but are nonspecific Serum ANA and antidouble-stranded DNA antibodies are also usually elevated without any evidence of lupus erythematosus or other collagen-vascular disease Since high levels of T4 and FT4 are normally seen in patients taking amiodarone, suppressed TSH (sensitive assay) must be present along with a greatly elevated T4 (> 20 mcg/dL) or T3 (> 200 ng/dL) in order to diagnose hyperthyroidism (Note: Hypothyroidism occurs in an additional 6% of patients receiving amiodarone after 2 39 weeks of therapy) In type I amiodarone-induced thyrotoxicosis, the presence of proptosis, TSH-R Ab[stim], or thyrotropin-binding inhibitory immunoglobulin (TBII) is diagnostic In type II amiodarone-induced thyrotoxicosis, serum levels of interleukin-6 (IL-6) are usually quite elevated Patients with subacute thyroiditis often have an increased erythrocyte sedimentation rate (ESR) Women with hyperthyroidism during pregnancy have an elevated FT4 while the TSH is suppressed However, apparent lack of full TSH suppression can be seen due to misidentification of hCG as TSH in certain assays Although the total T4 is elevated in most pregnant women, values over 20 mcg/ dL are encountered only in hyperthyroidism The T3 resin uptake, which is low in normal pregnancy because of high TBG concentration, is normal or high in thyrotoxic persons Pregnancy can have a beneficial effect on the thyrotoxicosis of Graves disease, with decreasing antibody titers and decreasing FT4 levels as the pregnancy advances.

seen in other conditions as well A low RAI uptake is characteristic of subacute thyroiditis but can also be seen in other conditions In the United States, thyroid RAI uptake is usually negligible in patients with type I amiodarone-induced thyrotoxicosis; however, in Europe, up to 80% of such patients have detectable or normal RAI uptake In type II amiodaroneinduced thyrotoxicosis, thyroid RAI uptake is very low MRI of the orbits is the imaging method of choice to visualize Graves ophthalmopathy affecting the extraocular muscles CT scanning and ultrasonography can also be used Imaging is required only in severe cases or in euthyroid exophthalmos that must be distinguished from orbital tumors or other disorders

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True thyrotoxicosis must be distinguished from those conditions elevating serum T4 and T3 or suppressing serum TSH without affecting clinical status Some states of hypermetabolism without thyrotoxicosis notably severe anemia, leukemia, polycythemia, and cancer rarely cause confusion Pheochromocytoma is often associated with hypermetabolism, tachycardia, weight loss, and profuse sweating Acromegaly may also produce tachycardia, sweating, and thyroid enlargement Appropriate laboratory tests will easily distinguish these entities Cardiac disease (eg, atrial fibrillation, angina) refractory to treatment suggests the possibility of underlying ( apathetic ) hyperthyroidism Other causes of ophthalmoplegia (eg, myasthenia gravis) and exophthalmos (eg, orbital tumor, pseudotumor) must be considered Thyrotoxicosis must also be considered in the differential diagnosis of muscle weakness and osteoporosis Diabetes mellitus and Addison s disease may coexist with thyrotoxicosis

Hypercalcemia, osteoporosis, and nephrocalcinosis may occur Decreased libido, impotence, decreased sperm count, and gynecomastia may be noted in men with hyperthyroidism Patients who have subclinical hyperthyroidism (suppressed TSH but normal FT4 and clinically euthyroid) generally do well without treatment In most such patients, serum TSH reverts to normal within 2 years No accelerated bone loss has been noted In one series, clinical hyperthyroidism developed in one of seven patients with subclinical hyperthyroidism after about 2 years

The treatment of Graves disease involves a choice of methods rather than a method of choice 1 Propranolol Propranolol is generally used for symptomatic relief until the hyperthyroidism is resolved It effectively relieves the tachycardia, tremor, diaphoresis, and anxiety that occur with hyperthyroidism due to any cause It is the initial treatment of choice for thyroid storm The periodic paralysis seen in association with thyrotoxicosis is also effectively treated with -blockade It has no effect on thyroid hormone secretion Treatment is usually begun with propranolol 20 mg orally, which is increased progressively until an adequate response is

Generally, the VAT registration number on the customer master record will be 11 characters long and begin with a prefix equal to that of the ISO code for the country for example, the VAT registration number for Germany is DE123456789

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