Night Sweats

See Also

Definitions

Night Sweats
1. Sweating at night despite sleeping conditions without excessive heat exposure

Epidemiology

Common symptom (Prevalence >5-10% depending on age)
Most common at age 41-55 years old (Incidence decreased to 5% after age 65 years)

Causes

Malignancy (e.g. Lymphoma or Leukemia)
1. Typically drenching Night Sweats, easy Bruising or bleeding and Unintentional Weight Loss
Rheumatologic Condition
1. Takayasu Arteritis (pulseless disease)
2. Sarcoidosis
3. Temporal Arteritis (Giant Cell Arteritis)
4. Rheumatoid Arthritis
Infection
1. HIV Infection (esp. AIDS and opportunistic infections)
2. Tuberculosis
3. Infectious Mononucleosis
4. Lyme Disease
5. Fungal infection (Histoplasmosis, Coccidioidomycosis)
6. Endocarditis
7. Pneumonia or Lung Abscess
8. Cysticercosis
Endocrinopathy
1. Menopause (See Hot Flashes)
2. Male Hypogonadism (Andropause)
3. Hyperthyroidism
4. Diabetes Mellitus
5. Diabetes Insipidus
6. Carcinoid Tumor (warm flushed skin with Night Sweats)
7. Pheochromocytoma (cool and pale skin with Night Sweats)
8. Obesity
9. Polycythemia Vera
10. Autonomic Dysreflexia
Medications
1. Acetaminophen
2. Aspirin
3. Antihypertensives (e.g. Beta Blockers)
4. Anticholinergics (e.g. Antihistamines)
5. Phenothiazines
6. Niacin (Flushing reaction)
7. Decongestants
8. Leuprolide (Lupron)
9. Corticosteroids
10. Levothyroxine
11. Protease Inhibitors (Indinavir, Saquinavir)
12. Monoclonal Antibody (Daclizumab, Rituximab)
13. Antineoplastics (Interferon alfa-2a, Pegaspargase)
14. Selective Serotonin Reuptake Inhibitors (e.g. Paroxetine)
15. Tricyclic Antidepressants
16. Angiotensin Receptor Blockers (e.g. Losartan)
17. Selective Estrogen Receptor Modulators (Tamoxifen)
18. Gonadotropin-Releasing Hormone Agonist
19. Antiandrogens
20. Hypoglycemic agents (Oral Hypoglycemics, Insulin)
21. Efavirenz (Sustiva)
Drugs of Abuse
1. Alcohol Abuse or Alcohol Withdrawal
2. Tobacco Abuse
3. Heroin Abuse and Withdrawal
Miscellaneous Causes
1. Obstructive Sleep Apnea
2. Gastroesophageal Reflux (GERD)
3. Anxiety Disorder
4. Pregnancy
5. Syringomyelia

Differential Diagnosis

Vasomotor Symptoms of Menopause
Anxiety Disorder (e.g. Panic Attacks, PTSD)
Obesity
Diabetes Mellitus
Gastroesophageal Reflux Disease
Environmental Factors
1. Excessive heat exposure
2. Inadequate heat dissipation (e.g. excessive bedding)

History

Infectious disease exposure
1. Febrile Illness
2. Mononucleosis
3. Tuberculosis
4. HIV Infection (esp. AIDS and opportunistic infections including Pneumocystis, Mycobacterium Avium Complex)
5. Endocarditis (ask about IV Drug Abuse)
6. Tick Borne Illness (e.g. Lyme Disease)
Travel History
Endocrine symptoms
1. Menopause (Amenorrhea)
2. Andropause (e.g. Erectile Dysfunction)
3. Hyperthyroidism symptoms (anxiety, Diarrhea, Tremor, weight loss, Palpitations)
4. Hypoglycemia symptoms
Habits
1. High sugar, high fat diet is associated with increased Night Sweats
  1. Mediterranean Diet in contrast is associated with decreased Night Sweats
2. Substance Use associated with Night Sweats
  1. Tobacco Abuse
  2. Alcohol use >3 drinks per day
3. IV Drug Abuse (e.g endocarditis, Drug Withdrawal)
Full Review of Systems for comorbid conditions
1. Evaluate for causes above
2. GERD Symptoms (e.g. Bitter or Metallic Taste on awakening)
3. Obstructive Sleep Apnea symptoms (snoring, witnessed apneas)
4. Carcinoid Tumor Symptoms (attacks of Abdominal Pain, watery Diarrhea, Flushing, Hypotension)

Exam
Focused on suspected causes

Body Weight
1. Evaluate for Unintentional Weight Loss >5% in the past 6-12 months
2. Cachexia suggests severe prolonged weight loss
Vital Signs
1. Temperature
  1. Follow Prolonged Fever protocol fo persistent or Recurrent Fever
2. Blood Pressure
Head and Neck Exam
1. Thyromegaly (associated with Exophthalmos, Tremor, Tachycardia) may be seen with Hyperthyroidism
2. Localized or Generalized Lymphadenopathy (esp. if present >4-6 weeks)
3. Oral Candidiasis (e.g. HIV Infection or AIDS)
4. Large neck circumference >16-17 cm or Mallampati Score 3-4 are risks for Obstructive Sleep Apnea
Cardiopulmonary Exam
1. New Heart Murmur (e.g. Endocarditis)
2. Weak Pulses (Takayasu Arteritis)
Abdominal Exam
1. Splenomegaly (e.g. Mononucleosis, Lymphoma)
Skin Changes
1. Petechiae or Purpura

Labs

First-line testing
1. Complete Blood Count (CBC)
2. Chest XRay
3. Mono Spot (consider EBV titers)
4. Purified Protein Derivative (PPD) or Quantiferon for Tuberculosis
5. Thyroid Stimulating Hormone
6. HIV Test
7. C-Reactive Protein
Second-line tests to consider
1. Blood Cultures (3 sets) if documented nocturnal fever spikes
  1. Include atypicals (e.g. Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
2. Tick Borne Illness testing (e.g. Lyme Disease, Babesiosis, Anaplasmosis)
3. Peri-Menopause Confirmation (Follicle Stimulating Hormone, Anti-Mullerian Hormone)
4. Bone Marrow Biopsy if suspected myeloproliferative or lymphoproliferative disorder

Imaging

First-Line Imaging
1. Chest XRay
Second-Line Imaging
1. Chest, Abdomen, Pelvis CT with IV contrast

Evaluation

Step 1
1. Evaluate for causes suggested by history and exam
2. Confirm up-to-date cancer screening appropriate for gender, age and risk factors
3. Encourage patient to keep a symptom diary along with measured Temperature
4. Empiric treatment for 4-8 weeks if likely cause identified by history and exam
  1. Proton Pump Inhibitor and lifestyle management trial for Esophageal Reflux
  2. Tobacco Cessation and Alcohol cessation (or decrease)
  3. Decrease or eliminate specifric medication causes
  4. Manage Anxiety Disorder
Step 2
1. Perform lab testing and first-line imaging as above
Step 3
1. Empiric treatment (e.g. PPI for GERD) as above, if not already performed
2. Consider second-line imaging (e.g. CT Chest, Abdomen and Pelvis)
3. Consider second-line testing as above

Management

See Vasomotor Symptoms of Menopause
Treat specific causes (see evaluation and causes as above)

Prognosis

Peristent Night Sweats in age >65 years is NOT associated with increased mortality (at least in prmary care)
1. Mold (2010) J Am Board Fam Med 23(1): 97-103 [PubMed]

References