Common Ambulatory Topic: Night Sweats

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Common Ambulatory Topic Night Sweats

• Christina M. Kile, MD
• June 5, 2007

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Roadmap

• Introduction
• Epidemiology
• Possible Differential Diagnosis
• Approach to History and Physical
• Suggested Evaluation
• Summary
• References

3
Definitions

• Night Sweats- drenching sweats that require
  changing bedclothes
• Hot Flashes- sudden sensation of heat on face and
  chest that rapidly becomes generalized and is
  associated with profuse sweating
• Flushing- warmth and redness of face and
  occasionally trunk

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Epidemiology

• Not much data in literature
• Studies are limited by
• Selection bias
• Lack of standard evaluation
• Variable follow up
• Prevalence estimates range from 10-40 depending
  on study definitions and setting

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Etiology

• Broad differential diagnosis
• Malignancy
• Infection
• Medications
• Endocrine causes
• Neurologic diseases
• Menopause
• Miscellaneous

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Malignancy

• Lymphoma
• Hodgkins Disease
• Non-Hodgkins Lymphoma
• Solid Tumors
• Prostate Cancer
• Renal Cell Carcinoma
• Germ Cell Tumors
• Advanced Medullary Carcinoma of the Thyroid
• Insulinoma

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Infections

• Tuberculosis
• Bacterial Infections
• Endocarditis, Osteomyelitis, Pyogenic Abscess
• HIV infection
• Mycobacterium avium Complex (MAC)
• Infectious Mononucleosis
• Fungal infections
• Histoplasmosis, Coccidiodomycosis

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Medications

• Antidepressants
• Anti-Migraine
• Antipyretics
• Hypoglycemic Agents
• Sympathomimetics
• Cholinergic Agonists
• GnRH Agonists

• Miscellaneous
• Alcohol and Drugs
• Antihypertensives
• Vasodilators
• Niacin
• Omeprazole
• Opiods
• Sildenafil
• Tramadol
• Tamoxifen

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Endocrine Disorders

• Pheochromocytoma
• Episodic headache, sweating and tachycardia
• Carcinoid Syndrome
• Flushing, diarrhea and wheezing
• Hyperthyroidism
• Increased sweating and heat intolerance
• Hypoglycemia

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Neurologic Disorders

• Autonomic Dysreflexia
• Post-traumatic Syringomyelia
• Stroke
• Autonomic Neuropathy

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Menopause

• Unclear distinction between perimenopausal hot
  flashes and night sweats (vasomotor symptoms)
• Median age 51 years
• Symptoms usually occur approximately 3 yrs
  earlier than change in menstrual pattern
• Do not assume night sweats in women are always
  related to hormonal changes

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Miscellaneous Causes

• Idiopathic Hyperhidrosis
• Gastroesophageal Reflux
• Chronic Fatigue Syndrome
• Panic Disorder, Anxiety or Depression
• Obstructive Sleep Apnea
• Over-bundling
• Pregnancy
• Temporal Arteritis

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The Challenge

• Extensive list of possible causes of night sweats
• No evidence-based approach available in
  literature
• Ideal approach is matter of opinion

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History

• Exclude Fever with certainty
• Search for Associated Symptoms
• Risk factors for Tuberculosis
• Risk factors for HIV infection
• Medication History

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Physical Exam

• Temperature (rule out occult fever)
• Heart Rate (pheochromocytoma, hyperthyroidism)
• Blood Pressure (pheochromocytoma)
• Weight and Body habitus (cachexia, obesity)
• HEENT (lid lag, exophthalmos, thrush, goiter,
  thyroid nodule)
• Skin (sweating pattern, endocarditis stigmata,
  hyperthyroidism changes)
• Lymph Node Exam (lymphoma)
• Cardiopulmonary (abnormal lung findings, new
  murmur)
• Abdomen (splenomegaly)

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Diagnostic Evaluation

• Stop offending Medication if possible
• Consider Temperature Diary
• Depends on Character of Night Sweats

Persistent Drenching Night Sweats that require
change of clothes
Proceed with Further Evaluation
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Diagnostic Considerations

• CXR
• PPD Test
• CBC
• TSH
• HIV Serology
• Blood Cultures
• HACEK organisms

• Others
• ESR
• CT Chest
• Bone Marrow Biopsy
• 24hr urine for 5-HIAA, metanephrines and
  catecholamines
• FSH

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If all studies negative?

• Reassurance that night sweats are likely benign
• Notify MD if new symptoms develop
• Continue regular medical examinations
• Patient can be taught self lymph node examination
  and report any changes noted

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Summary

• Night Sweats are common outpatient complaint
• Literature is scarce
• Differential Diagnosis is quite broad
• Thorough History and Physical is essential
• Diagnostic evaluation depends on findings of HP
  and severity of symptoms
• Recommendations are opinion based

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References

• Chambliss ML. What is the Appropriate Diagnostic
  Approach for Patients who complain of Night
  Sweats? Archives of Family Medicine. 1999
  8168-169.
• Lea M, Aber R. Descriptive Epidemiology of Night
  Sweats Upon Admission to a University Hospital.
  Southern Medical Journal. 1985 781065-7.
• Mold J, Mathew M, Belgore S, DeHaven M.
  Prevalence of Night Sweats in Primary Care
  Patients an OKPRN and TAFP-Net Collaborative
  Study. Journal of Family Practice. 2002
  5452-6.
• Mold J, Roberts M, Aboshady H. Prevalence and
  Predictors of Night Sweats, Day Sweats and Hot
  Flashes in Older Primary Care Patients An OKPRN
  Study. Annals of Family Medicine. 2004 2.
• Mold J, Wooley J, Nagykaldi Z. Association
  Between Night Sweats and Other Sleep
  Disturbances An OKPRN Study. Annals of Family
  Medicine. 2006 4 423-426.
• Prior J, Hitchcock C. Night Sweats Are Commonly
  Vasomotor Symptoms. American Family Physician.
  2004 70.
• Smetana, G. Approach to the Patient with Night
  Sweats. http//www.uptodate.com.
• Viera A, Bond M, Yates S. Diagnosing Night
  Sweats. American Family Physician. 2003 67
  1019-1024.