Intended for healthcare professionals

Rapid response to:

Endgames Case Report

A 42 year old man with bilateral exophthalmos and weight loss

BMJ 2011; 342 doi: (Published 23 March 2011) Cite this as: BMJ 2011;342:d1105

Rapid Response:

TSH receptor antibodies in Graves' disease

The role of TSH receptor antibodies (TRAbs) in the pathogenesis of
Graves' disease has been recognized for several decades. However, the
practical application of TRAbs in clinical settings is less clear. Whilst
the diagnosis of Graves' disease can be made with sufficient certainty
based on clinical features in most patients with the condition[1], the
TRAb test can be useful when pathognomonic features are lacking and in
ambiguous clinical scenarios such as euthyroid ophthalmopathy, unilateral
exophthalmos, painless thyroiditis, subclinical hyperthyroidism,
thyrotoxicosis associated with hyperemesis gravidarum and amiodarone-
induced thyrotoxicosis [2]. TRAb titres can also help to distinguish
thyrotoxicosis due to Graves' disease from that caused by toxic
multinodular goitres in areas with high background prevalence of nodular
thyroid disease due to low iodine intake [3]. They are of particular value
in assessing the risk of neonatal thyroid dysfunction from transplacental
migration of antibodies in pregnant women with a history of Graves'
disease [4]. Cost effectiveness, reliability and availability have been
limiting factors in the uptake of the TRAb test in routine clinical
practice in previous years. With the development of automated third
generation assays with sensitivity of 99% and specificity of 99% [5], TRAb
tests are becoming more reliable, affordable and more widely available and
warrant more serious consideration in the management of patients with

David C. Matthews, medical student

Akheel A. Syed, consultant endocrinologist

The University of Manchester, Oxford Road, Manchester, M13 9PL,
United Kingdom

Competing Interests: Nil


1. Tigas S, Tsatsoulis A. A 42 year old man with bilateral exophthalmos
and weight loss. BMJ 2011;342:d1105.

2. Matthews DC, Syed AA. The role of TSH receptor antibodies in the
management of Graves' disease. Eur J Intern Med 2011;

3. Pedersen IB, Knudsen N, Perrild H, Ovesen L, Laurberg P. TSH-receptor
antibody measurement for differentiation of hyperthyroidism into Graves'
disease and multinodular toxic goitre: a comparison of two competitive
binding assays. Clin Endocrinol (Oxf) 2001;55(3):381-90.

4. Laurberg P, Bournaud C, Karmisholt J, Orgiazzi J. Management of Graves'
hyperthyroidism in pregnancy: focus on both maternal and foetal thyroid
function, and caution against surgical thyroidectomy in pregnancy. Eur J
Endocrinol 2009;160(1):1-8.

5. Schott M, Hermsen D, Broecker-Preuss M, Casati M, Mas JC, Eckstein A,
et al. Clinical value of the first automated TSH receptor autoantibody
assay for the diagnosis of Graves' disease (GD): an international
multicentre trial. Clin Endocrinol (Oxf) 2009;71(4):566-73.

Competing interests: No competing interests

28 March 2011
David C. Matthews
Medical Student
Akheel A. Syed
University of Manchester