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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

Approach to Night Sweats

Jeffrey P Schaefer, MD

January 10, 2007

objectives
Objectives
  • Definition
  • Frequency
  • Differential Diagnosis
  • Work-up
slide8
1 sentence

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

lay internet
Lay Internet
  • 8 causes of night sweats
  • buy some Ensure
lay internet10
Lay Internet

‘Avoid alcohol and spicy food’

- buy a gadget

slide11
682 hits
  • majority are disease oriented
    • case reports
    • little quantitative data
  • no ‘economic analyses’
  • no ‘comparison of diagnostic strategy’
reference 1
Reference 1

Am Fam Phys

2003;67:1019-24

reference 2
Reference 2

www.uptodate.com

October, 2005

night sweats
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
definition
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)
what makes us sweat
What makes us sweat?
  • Glands
    • eccrine (generalized - watery)
    • apocrine (perianal / genital - sialomucin)
    • apoeccrine (axillae - hybrid)
  • Stumuli
    • thermoregulatory sweating
    • emotional sweating
    • gustatory sweating
pathophysiology of night sweats
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
frequency of night sweats j family practice 2002 51 452 6
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
frequency of night sweats j family practice 2002 51 452 619
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
slide20

Pure Night Sweats: 20 – 25%

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

Any night sweats ~40%

frequency of reporting
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
slide22

Pure Night Sweats

All: Panic Attacks

Men: Sleep Problems

Women: Hot Flashes & Panic Attacks

slide23

Day and Night Sweats

hot flashes

chronic infection

sleep problems

TCA

Xanthines

Other Anti-depressants

Weight

Anti-histamines

Alcohol

uptodate drug list
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
clinical evaluation
Clinical Evaluation

Journal Article…

“Thorough history and physical examination”

diagnostic work up am fam pract 2003
Diagnostic Work-upAm Fam Pract 2003
  • Like any diagnostic regimen…
  • depends on pre-test probability of disease!
jp schaefer approach
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.
clinical evaluation32
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?)
jp schaefer ddx
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
physical features
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
lab work up no set timing
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
work up of even less certain utility
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
friend foe time
Friend / Foe: Time
  • Neoplasms
  • Inflammatory Disease
  • Infectious Diseases
  • Improbable that these will not ‘come to light’ after 6 – 12 months.
all negative now what
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
therapies
Therapies
  • Empiric trial for GERD…
  • Eliminate unnecessary medication
    • good time to stop the sed / hypnotic
  • No alcohol for 4 – 8 weeks
  • Food elimination trial?
summary
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
slide41
No conflicts to declare
  • Thank you for your time

Questions?

Experiences to share?

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