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Approach to Night Sweats. Jeffrey P Schaefer, MD January 10, 2007. Objectives. Definition Frequency Differential Diagnosis Work-up. What do we actually know?. Not much. Nothing. Incidental References to Night Sweats. Nothing. Nothing Useful. 1 sentence

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Approach to night sweats l.jpg

Approach to Night Sweats

Jeffrey P Schaefer, MD

January 10, 2007


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Objectives

  • Definition

  • Frequency

  • Differential Diagnosis

  • Work-up







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1 sentence

“Night sweats may accompany an elevated temperature at night.”


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Lay Internet

  • 8 causes of night sweats

  • buy some Ensure


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Lay Internet

‘Avoid alcohol and spicy food’

- buy a gadget


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  • 682 hits

  • majority are disease oriented

    • case reports

    • little quantitative data

  • no ‘economic analyses’

  • no ‘comparison of diagnostic strategy’


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Reference 1

Am Fam Phys

2003;67:1019-24


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Reference 2

www.uptodate.com

October, 2005


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Night Sweats

  • Symptom

    • variably defined

    • variably distressing

  • Etiological Relationships

    • exaggeration of a normal body function

    • no / unknown temporal relationship to the majority of its causes


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Definition

  • Night Sweats are:

    • drenching sweats that require changing bedclothes

  • Excludes:

    • the appropriate response to the environment

    • menopausal / perimenopausal ‘hot flashes’

    • idiopathic hyperhidrosis (24 hr phenomenon)


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What makes us sweat?

  • Glands

    • eccrine (generalized - watery)

    • apocrine (perianal / genital - sialomucin)

    • apoeccrine (axillae - hybrid)

  • Stumuli

    • thermoregulatory sweating

    • emotional sweating

    • gustatory sweating


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Pathophysiology of Night Sweats

  • Not much known

  • Could speculate:

    • circadian rhythm

    • CNS effects

    • inflammatory mediators

    • etc, etc, etc…

    • 6 / 6 with lymphoma  subtle (0.5 – 1.0 C) body temperature increase < 30 min prior to the night sweat


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Frequency of Night SweatsJ Family Practice 2002;51:452-6

  • Lit Review – 3 articles:

    • 174 inpatients

      • non-obstetric patients 30% within last 3 mo

      • obstetric patients 60% within last 3 mo

      • 25% of all  required bath & linen change

    • 200 GI clinic patients

      • 40% recalled a night sweat last 1 yr

      • 12% weekly night sweat

    • 750 geriatric patients

      • 10% within last 1 month


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Frequency of Night SweatsJ Family Practice 2002;51:452-6

Prospective Study

  • Night Sweats

    • sweating at night when room is not excessively warm

  • Day Sweats

    • excessive sweating during the daytime

  • Pure Night Sweats

    • night, not day

  • Night and Day

    • both


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Pure Night Sweats: 20 – 25%

Day and Night Sweats: Men ~15% Women 25%

Any night sweats ~40%


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Frequency of Reporting

  • 12% of all reported their symptoms

  • 46% of severe reported their symptoms

  • More likely to report if:

    • older

    • bothered someone else

    • other menopausal symptoms / estrogen


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Pure Night Sweats

All: Panic Attacks

Men: Sleep Problems

Women: Hot Flashes & Panic Attacks


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Day and Night Sweats

hot flashes

chronic infection

sleep problems

TCA

Xanthines

Other Anti-depressants

Weight

Anti-histamines

Alcohol




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Uptodate Drug List

  • Antidepressants

    • SSRI, Bupropion, TCA, Venlafaxine

  • Anti-migraine drugs

    • Naratriptan, Rizatriptan, Sumatriptan, Zolmitriptan

  • Antipyretics

    • Acetaminophen, Aspirin, NSAIDs

  • Cholinergic agonists

    • Bethanecol, Pilocarpine

  • GnRH agonists

    • Gonadorelin, Goserelin, Histrelin, Leuprolide, Nafarelin

  • Hypoglycemic agents

    • Insulin, Sulfonylureas

  • Sympathomimetic agents

    • Beta-agonists, Phenylephrine

  • Other

    • Alcohol, Beta blockers, Bromocriptine, Calcium channel blockers, Clozapine, Cyclosporine, Hydralazine, Niacin, Nitroglycerin, Omeprazole, Opioids, Sildenafil, Tamoxifen, Theophylline, Tramadol


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Clinical Evaluation

Journal Article…

“Thorough history and physical examination”


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Diagnostic Work-upAm Fam Pract 2003

  • Like any diagnostic regimen…

  • depends on pre-test probability of disease!


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JP Schaefer Approach

Given

  • I’ve never diagnosed an new illness that presented solely with night sweats.

  • The presence of night sweats do not appreciably alter the probability of any disease.

  • Patients (and referring physicians) have expectations.


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Clinical Evaluation

  • why do we diagnose?

    • predict the natural history of wellness & illness

    • influence the outcome of wellness & illness

  • how do we diagnose? (symptoms like lab tests)

    • sensitivity, specificity, positive (neg) predictive values

    • liklihood ratios

    • night sweats  very non-specific (possibly useless?)


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JP Schaefer DDx

  • Document symptom duration.

  • What conditions:

    • should we avoid missing?

    • may not be clinically obvious?

  • Infections

    • bacteremia, tuberculosis, HIV

  • Neoplasm

    • all

  • Inflammatory Disease

    • nephritis, temporal arteritis

  • Hormone

    • hypoglycemia, hyperthyroidism, pregnancy


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Physical Features

  • Don’t miss…

    • weight loss

    • fever  patient keeps temp diary

    • hypertension (pheo)

    • malignant skin lesions

    • lymphadenopathy

    • murmurs

    • abdominal masses

    • scrotal / prostate / cervix / breast masses

    • arthritis


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Lab Work-up  No set timing

  • CBC: leukemia, cytopenia

  • Lytes, Creat, Urinalysis:nephritis (osis)

  • ALT & ALP: auto-immune and viral hepatitis

  • Ferritin: hemachromatosis (1:272)

  • ESR: temperal arteritis

  • Glucose +/- glucometry: diabetes mellitus

  • Ca, Alb, SPE: myeloma

  • TSH: hyperthyroidism

  • Blood Culture: bacteremia

  • +/- Pregnancy Test +/- HIV serology

  • CXR + U/S abdomen / pelvis OR

  • CT Chest – Abdomen - Pelvis


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Work-up of even less certain utility…

  • Think ‘fever of unknown origin’

  • Tuberculin

  • Bone scan

  • Bone Marrow Aspiration and Biopsy

  • Gastroscopy / Colonoscopy

  • CT head  sinusitis

  • MRI head  Multiple Sclerosis


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Friend / Foe: Time

  • Neoplasms

  • Inflammatory Disease

  • Infectious Diseases

  • Improbable that these will not ‘come to light’ after 6 – 12 months.


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All Negative… Now what?

  • Educate patients about the frequency and non-specific nature of night sweats.

  • Ask patients to monitor for:

    • weight loss

    • fever (thermometer)

    • unexplained pain

    • symptoms of sleep apnea and reflux

  • Reassessment


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Therapies

  • Empiric trial for GERD…

  • Eliminate unnecessary medication

    • good time to stop the sed / hypnotic

  • No alcohol for 4 – 8 weeks

  • Food elimination trial?


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Summary

  • Night sweats…

    • variably defined

    • 1/5 adults have them

    • non-specific symptom

    • wide differential diagnosis

    • clinical assessment  disease directed

    • paraclinical assessment 

      • driven by value judgments as much as science


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