VA Ambulatory Report 12.20.17 – Night Sweats for a Decade and the Million Dollar work-up

Thank you Dan for presenting this great ambulatory care.  We discussed a young male with a decade of night sweats with unremarkable work-up whose symptoms improved  after starting an alpha-blocker.  We had an interesting discussion of psychological disorders such as PTSD and anxiety as a cause of night sweats.

Night sweats

  • Pathologic =  drenching sweats that require changing pajamas or sheets
  • LT pearl Pathologic night sweats occur as result of the exaggeration of the normal diurnal temperature changes.
    • Max temperature occurs at 10pm
    • Sweating occurs in the following 2-4 hours. Therefore pathologic night sweats almost always occur after midnight

Approach to a patient with night sweats

  • A similar approach can be used with a patient with flushing or diffuse hyperhidrosis)
  • Break down by organ system
    • Malignancy
      • Lymphoma
      • Solid tumors: germ cell, medullary thyroid, RCC, prostate
    • Infections
      • Mycobacterial
      • Bacterial: Abscess, brucellosis, endocarditis, osteomyelitis
      • Fungal:
      • Viral: HIV, HCV
    • Endocrine
      • Carcinoid
      • DI
      • hyperthyroid
      • Pheo
      • Post-orchiectomy
      • Ovarian Failure
    • Medications: The list is extensive.  Some are more likely to cause flushing vs. night sweats
    • Substance withdrawal
      • Alcohol, cocaine, opiates
    • Neuro
      • Autoimic dysreflexia, autonomic neuropathy, stroke
    • Other/Mimickers
      • Hot flashes from Menopause
      • Overbundling
      • Hypoglycemia
      • OSA
      • PTSD
      • Panic disorder
      • Chronic fatigue syndrome
      • Food additives
      • GERD
        • There is an association between GERD and night sweats and some evidence patient’s symptoms improve after treatment with antireflux meds
      • Mastocytosis
      • Temporal arteritis
      • Takayasu’s arteritis
      • Idiopathic hyperhidrosis
      • Roseacea

How can we evaluate this non-specific compliant in a cost-effective manner?

  • Key is a focused history and physical to help target your diagnostic work-up
  • Always review the medication list
  • If no clear localized signs or symptoms the AAFP suggests a step-wise approach
    • Step 1: CBC, ppd, TSH, CXR
    • Step 2: HIV, ESR
    • Step 3: Trial of anti-reflux meds
    • Step 4: Diary of noctural temperature
    • Step 5: Blood cultures specifically looking for HACEK organisms
    • Step 6: Consider CT abdomen, CT chest, and/or Bone Marrow biopsy
    • Step 7: Reassurance and monitoring for new symptoms
  • Check out the full article here: AAFP Article on the Diagnosis of night sweats.

Link to Evernote:


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