Night Sweats
Night Sweats: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Mark Bajorek
Night sweats are drenching sweats that require a change of bedding (1).
Approach.
The first priority is to exclude night sweats caused by fever. Sweating associated with fever is a separate evaluation (Chapter 2.6). Before the 20th century, night sweats implied infection with tuberculosis. Now, many other ailments are associated with this symptom. Night sweats are often the mark of a known condition such as diabetes (especially with nocturnal hypoglycemia), cancer, head trauma, and rheumatologic disorders. Night sweats can also be a symptom of a new disorder. The investigation of a patient reporting night sweats requires a review of past illnesses and new symptoms.
History.
Night sweats can be characterized by determining onset, frequency, exacerbations, and remissions of symptoms. Question patients about the current state of known disorders. Excessive sweating is associated with poor nocturnal glycemic control (Chapter 14.1). Flares of rheumatologic disorders (rheumatoid arthritis, lupus, juvenile rheumatoid arthritis, and temporal arteritis) cause sweating too. Pregnancy temporarily changes the intrinsic thermostat in many women who perspire excessively (2). Patients who are immunocompromised are at increased risk for infections, especially with atypical agents. Patients with a history of substance abuse need to be asked about needle use and contaminants.
A. Review of systems. Other symptoms that can accompany night sweats include flushing (carcinoid syndrome, pheochromocytoma), joint pain, sleep apnea, menstrual irregularities, reflux, cough, headache, dysuria, dyspnea, rashes, fatigue, palpitations, and weight and bowel habit changes.
B. Exposure factors. Inquire about recent immunizations or new medicines such as antidepressants (3), cholinergics, meperidine, estrogen inhibitors, gonadotropin inhibitors, niacin, steroids, stimulants, over-the-counter preparations, antipyretics, and naturopathic therapies. Question patients about exposure to sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), hepatitis, tuberculosis, or occupational and travel-related exposures. Also ask about increases in general changes in the ambient night temperature.
C. Psychological factors. Anxiety, nightmares, and psychoactive preparations can precipitate night sweats in healthy individuals.
D. Family history. Patients who report a family history of hereditary disorders and possible malignancies should have appropriate screening.
Physical examination.
The physical examination should address the pertinent positives noted in the patient’s medical history. Note the patient’s weight and temperature. Examination of the head, eyes, ears, nose, and throat (HEENT) should focus on common types of infection: sinusitis, pharyngitis, and otitis. A thorough examination of lymph nodes is helpful to identify infection or lymphatic abnormalities (Chapter 15.1). The cardiopulmonary examination can also signal infection, valvular disease, and stimulant use. Patients should be examined for abscesses, skin ulcers, septic joints, phlebitis, and osteomyelitis.
Testing
A. Clinical laboratory testing. For patients with a known condition, testing for exacerbations is appropriate: erythrocyte sedimentation rate (infection, osteomyelitis, and temporal arteritis), C-reactive protein (rheumatologic disorders), and hemoglobin A1C (diabetes mellitus). Depending on the patient’s symptoms or exposures, other appropriate tests can include purified protein derivative skin test for tuberculosis, free T4 level to rule out thyrotoxicosis, complete blood count with differential (infection), and follicle-stimulating hormone to investigate the possibility of menopause. Special tests may be required of patients with travel-related or STD exposures.
B. Imaging. Chest x-ray studies are useful in the evaluation of night sweats in patients with a smoking history, industrial exposure, or a cough. These patients need to be screened for occult malignancy. Computed tomography scans are generally not appropriate unless other signs or symptoms dictate further evaluation.
Diagnostic assessment
. Night sweating as a single entity is not worrisome. Explore the likelihood of exacerbation of known conditions or the onset of a new disease process. The history is the most helpful part of the patient encounter. A new medication, with perspiration as a side effect, is often the culprit. Patients may need cessation of the medication as well as a washout period. Night sweats might be an early symptom of a developing illness so watchful waiting is useful (4). Patients need to be instructed to watch for weight changes, fevers, and sleep and mood changes. Patients can complete a symptom diary, which is very helpful to the clinician in determining the need for additional evaluation. Consider illnesses that tend to be present in the patient’s age group. Screening for common malignancies through mammograms, pap smears, and fecal occult blood testing is appropriate health maintenance as well as often being a part of the evaluation of the presenting complaint of night sweats.
References
1. Smetana GW. Diagnosis of night sweats. JAMA 1993;70:2502–2503.
2. Lea MJ, Aber RC. Descriptive epidemiology of night sweats upon admission to a university hospital. South Med J 1985;78:1065–1072.
3. Babbott SF, Pearson VE. Sertraline-related night sweats. Ann Intern Med 1999;
130:242–243.
4. Chambliss ML. Frequently asked questions from clinical practice. What is the appropriate diagnostic approach for patients who complain of night sweats? Arch Fam Med 1999;2:168–169.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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