Diaphoresis
Diaphoresis: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Diaphoresis is profuse sweating, sometimes amounting to more than 1 L of sweat per hour. This sign represents an autonomic nervous system response to physical or psychogenic stress, fever, or high environmental temperature. When caused by stress, diaphoresis may be generalized or limited to the palms, soles, and forehead. When caused by fever or high environmental temperature, it’s usually generalized.
Diaphoresis usually begins abruptly and may be accompanied by other autonomic system signs, such as tachycardia and increased blood pressure. However, this sign also varies with age because sweat glands function immaturely in infants and are less active in elderly people. As a result, patients in these age-groups may fail to display diaphoresis associated with its common causes. Intermittent diaphoresis may accompany chronic disorders characterized by recurrent fever; isolated diaphoresis may mark an episode of acute pain or fever. Night sweats may characterize intermittent fever because body temperature tends to return to normal between 2 a.m. and 4 a.m. before rising again. (Temperature is usually lowest around 6 a.m.)
Diaphoresis is a normal response to high external temperature. Acclimatization usually requires several days of exposure to high temperatures; during this process, diaphoresis helps maintain normal body temperature. Diaphoresis also commonly occurs during menopause, preceded by a sensation of intense heat (a hot flash). Other causes include exercise or exertion that accelerates metabolism, creating internal heat, and mild to moderate anxiety that helps initiate the fight-or-flight response. (See Understanding diaphoresis.)
History and physical examination
If the patient is diaphoretic, quickly rule out the possibility of a life-threatening cause. (See When diaphoresis spells crisis, page 238.) Begin the history by having the patient describe his chief complaint. Then explore associated signs and symptoms. Note general fatigue and weakness. Does the patient have insomnia, headache, and changes in vision or hearing? Is he often dizzy? Does he have palpitations? Ask about pleuritic pain, cough, sputum, difficulty breathing, nausea, vomiting, abdominal pain, and altered elimination habits. Ask the female patient about amenorrhea and any changes in her menstrual cycle. Is she menopausal? Ask about paresthesia, muscle cramps or stiffness, and joint pain. Has she noticed any changes in elimination habits? Note weight loss or gain. Has she had to change her glove or shoe size lately?
Complete the history by asking about travel to tropical countries. Note recent exposure to high environmental temperatures or to pesticides. Did the patient recently experience an insect bite? Check for a history of partial gastrectomy or of drug or alcohol abuse. Finally, obtain a thorough drug history.
Next, perform a physical examination. First, determine the extent of diaphoresis by inspecting the trunk and extremities as well as the palms, soles, and forehead. Also, check the patient’s clothing and bedding for dampness. Note whether diaphoresis occurs during the day or at night. Observe the patient for flushing, abnormal skin texture or lesions, and an increased amount of coarse body hair. Note poor skin turgor and dry mucous membranes. Check for splinter hemorrhages and Plummer’s nails (separation of the fingernail ends from the nail beds).
Then evaluate the patient’s mental status and take his vital signs. Observe the patient for fasciculations and flaccid paralysis. Be alert for seizures. Note the patient’s facial expression, and examine the eyes for pupillary dilation or constriction, exophthalmos, and excessive tearing. Test visual fields. Also, check for hearing loss and for tooth or gum disease. Percuss the lungs for dullness, and auscultate for crackles, diminished or bronchial breath sounds, and increased vocal fremitus. Look for decreased respiratory excursion. Palpate for lymphadenopathy and hepatosplenomegaly.
Medical causes
Acquired immunodeficiency syndrome
Night sweats may be an early feature, occurring either as a manifestation of the disease itself or secondary to an opportunistic infection. The patient also displays fever, fatigue, lymphadenopathy, anorexia, dramatic and unexplained weight loss, diarrhea, and a persistent cough.
Acromegaly
In this slowly progressive disorder, diaphoresis is a sensitive gauge of disease activity, which involves hypersecretion of growth hormone and increased metabolic rate. The patient has a hulking appearance with an enlarged supraorbital ridge and thickened ears and nose. Other signs and symptoms include warm, oily, thickened skin; enlarged hands, feet, and jaw; joint pain; weight gain; hoarseness; and increased coarse body hair. Increased blood pressure, severe headache, and visual field deficits or blindness may also occur.
Anxiety disorders
Acute anxiety characterizes panic, whereas chronic anxiety characterizes phobias, conversion disorders, obsessions, and compulsions. Whether acute or chronic, anxiety may cause sympathetic stimulation, resulting in diaphoresis. The diaphoresis is most dramatic on the palms, soles, and forehead and is accompanied by palpitations, tachycardia, tachypnea, tremors, and GI distress. Psychological signs and symptoms—fear, difficulty concentrating, and behavior changes—also occur.
Autonomic hyperreflexia
Occurring after resolution of spinal shock in a spinal cord injury above T6, hyperreflexia causes profuse diaphoresis, pounding headache, blurred vision, and dramatically elevated blood pressure. Diaphoresis occurs above the level of the injury, especially on the forehead, and is accompanied by flushing. Other findings include restlessness, nausea, nasal congestion, and bradycardia.
Drug and alcohol withdrawal syndromes
Withdrawal from alcohol or an opioid analgesic may cause generalized diaphoresis, dilated pupils, tachycardia, tremors, and altered mental status (confusion, delusions, hallucinations, agitation). Associated signs and symptoms include severe muscle cramps, generalized paresthesia, tachypnea, increased or decreased blood pressure and, possibly, seizures. Nausea and vomiting are common.
Empyema
Pus accumulation in the pleural space leads to drenching night sweats and fever. The patient also complains of chest pain, cough, and weight loss. Examination reveals decreased respiratory excursion on the affected side and absent or distant breath sounds.
Heart failure
Typically, diaphoresis follows fatigue, dyspnea, orthopnea, and tachycardia in patients with left-sided heart failure, and jugular vein distention and dry cough in patients with right-sided heart failure. Other features include tachypnea, cyanosis, dependent edema, crackles, ventricular gallop, and anxiety.
Heat exhaustion
Although this condition is marked by failure of heat to dissipate, it initially may cause profuse diaphoresis, fatigue, weakness, and anxiety. These signs and symptoms may progress to circulatory collapse and shock (marked by confusion, thready pulse, hypotension, tachycardia, and cold, clammy skin). Other features include an ashen gray appearance, dilated pupils, and normal or subnormal temperature.
Hodgkin’s disease
Especially in elderly patients, early features of Hodgkin’s disease may include night sweats, fever, fatigue, pruritus, and weight loss. Usually, however, this disease initially causes painless swelling of a cervical lymph node. Occasionally, a Pel-Ebstein fever pattern is present—several days or weeks of fever and chills alternating with afebrile periods with no chills. Systemic signs and symptoms—such as weight loss, fever, and night sweats—indicate a poor prognosis. Progressive lymphadenopathy eventually causes widespread effects, such as hepatomegaly and dyspnea.
Hypoglycemia
Rapidly induced hypoglycemia may cause diaphoresis accompanied by irritability, tremors, hypotension, blurred vision, tachycardia, hunger, and loss of consciousness.
Immunoblastic lymphadenopathy
Resembling Hodgkin’s disease but rarer, this disorder causes episodic diaphoresis along with fever, weight loss, weakness, generalized lymphadenopathy, rash, and hepatosplenomegaly.
Infective endocarditis (subacute)
Generalized night sweats occur early in this disorder and are accompanyied by intermittent low-grade fever, weakness, fatigue, anorexia, weight loss, and arthralgia. A sudden change in a murmur or the discovery of a new murmur is a classic sign. Petechiae and splinter hemorrhages are also common.
Liver abscess
Signs and symptoms vary, depending on the extent of the abscess, but commonly include diaphoresis, right-upper-quadrant pain, weight loss, fever, chills, nausea, vomiting, and signs of anemia.
Lung abscess
Drenching night sweats are common in this disorder. Its chief sign, however, is a cough that produces copious amounts of purulent, foul-smelling, and typically blood-tinged sputum. Associated findings include fever with chills, pleuritic chest pain, dyspnea, weakness, anorexia, weight loss, headache, malaise, clubbing, tubular or amphoric breath sounds, and dullness on percussion.
Malaria
Profuse diaphoresis marks the third stage of paroxysmal malaria, preceded by chills (first stage) and high fever (second stage). Headache, arthralgia, and hepatosplenomegaly may also occur. In the benign form of malaria, these paroxysms alternate with periods of well-being. The severe form may progress to delirium, seizures, and coma.
Ménière’s disease
Characterized by severe vertigo, tinnitus, and hearing loss, this disorder may also cause diaphoresis, nausea, vomiting, and nystagmus. Hearing loss may be progressive and tinnitus may persist between attacks.
Myocardial infarction
Diaphoresis usually accompanies acute, substernal, radiating chest pain in this life-threatening disorder. Associated signs and symptoms include anxiety, dyspnea, nausea, vomiting, tachycardia, irregular pulse, blood pressure change, fine crackles, pallor, and clammy skin.
Pheochromocytoma
This disorder commonly produces diaphoresis, but its cardinal sign is persistent or paroxysmal hypertension. Other effects include headache, palpitations, tachycardia, anxiety, tremors, pallor, flushing, paresthesia, abdominal pain, tachypnea, nausea, vomiting, and orthostatic hypotension.
Pneumonia
In patients with pneumonia, intermittent, generalized diaphoresis accompanies fever, chills, and pleuritic chest pain that increases with deep inspiration. Other features are tachypnea, dyspnea, a productive cough (with scant and mucoid or copious and purulent sputum), headache, fatigue, myalgia, abdominal pain, anorexia, and cyanosis. Auscultation reveals bronchial breath sounds.
Relapsing fever
Profuse diaphoresis marks resolution of the crisis stage of this disorder, which typically produces attacks of high fever accompanied by severe myalgia, headache, arthralgia, diarrhea, vomiting, coughing, and eye or chest pain. Splenomegaly is common, but hepatomegaly and lymphadenopathy may also occur. The patient may develop a transient macular rash. Between 3 and 10 days after onset, the febrile attack abruptly terminates in chills with increased pulse and respiratory rates. Diaphoresis, flushing, and hypotension may then lead to circulatory collapse and death. Relapse invariably occurs if the patient survives the initial attack.
Tetanus
This disorder commonly causes profuse sweating accompanied by low-grade fever, tachycardia, and hyperactive deep tendon reflexes. Early restlessness and pain and stiffness in the jaw, abdomen, and back progress to spasms associated with lockjaw, risus sardonicus, dysphagia, and opisthotonos. Laryngospasm may result in cyanosis or sudden death by asphyxiation.
Thyrotoxicosis
This disorder commonly produces diaphoresis accompanied by heat intolerance, weight loss despite increased appetite, tachycardia, palpitations, an enlarged thyroid, dyspnea, nervousness, diarrhea, tremors, Plummer’s nails and, possibly, exophthalmos. Gallops may also occur.
Tuberculosis (TB)
Although many patients with primary infection are asymptomatic, TB may cause night sweats, low-grade fever, fatigue, weakness, anorexia, and weight loss. In reactivation, a productive cough with mucopurulent sputum, occasional hemoptysis, and chest pain may be present.
Other causes
Drugs
Sympathomimetics, certain antipsychotics, thyroid hormone, corticosteroids, and antipyretics may cause diaphoresis. Aspirin and acetaminophen poisoning also cause this sign.
Dumping syndrome
The result of rapid emptying of gastric contents into the small intestine after partial gastrectomy, dumping syndrome causes diaphoresis, palpitations, profound weakness, epigastric distress, nausea, and explosive diarrhea soon after eating.
Envenomation
Depending on the type of bite, neurotoxic effects may include diaphoresis, chills (with or without fever), weakness, dizziness, blurred vision, increased salivation, nausea and vomiting and, possibly, paresthesia and muscle fasciculations. Local features may include ecchymosis and progressively severe pain and edema. Palpation reveals tender regional lymph nodes.
Pesticide poisoning
Among the toxic effects of pesticides are diaphoresis, nausea, vomiting, diarrhea, blurred vision, miosis, and excessive lacrimation and salivation. The patient may also display fasciculations, muscle weakness, and flaccid paralysis. Signs of respiratory depression and coma may also occur.
Special considerations
After an episode of diaphoresis, sponge the patient’s face and body and change wet clothes and sheets. To prevent skin irritation, dust skin folds in the groin and axillae and under pendulous breasts with cornstarch, or tuck gauze or cloth into the folds. Encourage regular bathing.
Replace fluids and electrolytes. Regulate infusions of I.V. saline or Ringer’s lactate solution, and monitor urine output. Encourage intake of oral fluids high in electrolytes (such as Gatorade). Enforce bed rest and maintain a quiet environment. Keep the patient’s room temperature moderate to prevent additional diaphoresis.
Prepare thepatient for diagnostic tests, such as blood tests, cultures, chest X-rays, immunologic studies, biopsy, computed tomography scan, and audiometry. Monitor the patient’s vital signs, including temperature.
Pediatric pointers
Diaphoresis in children commonly results from environmental heat or overdressing the child; it’s usually most apparent around the head. Other causes include drug withdrawal associated with maternal addiction, heart failure, thyrotoxicosis, and the effects of such drugs as antihistamines, ephedrine, haloperidol, and thyroid hormone.
Assess fluid status carefully. Some fluid loss through diaphoresis may precipitate hypovolemia more rapidly in a child than an adult. Monitor input and output, weigh the child daily, and note the duration of each episode of diaphoresis.
Geriatric pointers
Elderly patients with TB may exhibit a change in activity or weight rather than the hallmark symptoms of fever and night sweats. Also, keep in mind that older patients may not exhibit diaphoresis because of a decreased sweating mechanism. For this reason, they’re at increased risk for developing heatstroke in high temperatures.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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