II. Definitions
- Night Sweats
- Sweating at night despite sleeping conditions without excessive heat exposure
III. 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)
IV. Causes
- Malignancy (e.g. Lymphoma or Leukemia)
- Typically drenching Night Sweats, easy Bruising or bleeding and Unintentional Weight Loss
-
Rheumatologic Condition
- Takayasu Arteritis (pulseless disease)
- Sarcoidosis
- Temporal Arteritis (Giant Cell Arteritis)
- Rheumatoid Arthritis
- Infection
- HIV Infection (esp. AIDS and opportunistic infections)
- Tuberculosis
- Infectious Mononucleosis
- Lyme Disease
- Fungal infection (Histoplasmosis, Coccidioidomycosis)
- Endocarditis
- Pneumonia or Lung Abscess
- Cysticercosis
- Endocrinopathy
- Menopause (See Hot Flashes)
- Male Hypogonadism (Andropause)
- Hyperthyroidism
- Diabetes Mellitus
- Diabetes Insipidus
- Carcinoid Tumor (warm flushed skin with Night Sweats)
- Pheochromocytoma (cool and pale skin with Night Sweats)
- Obesity
- Polycythemia Vera
- Autonomic Dysreflexia
- Medications
- Acetaminophen
- Aspirin
- Antihypertensives (e.g. Beta Blockers)
- Anticholinergics (e.g. Antihistamines)
- Phenothiazines
- Niacin (Flushing reaction)
- Decongestants
- Leuprolide (Lupron)
- Corticosteroids
- Levothyroxine
- Protease Inhibitors (Indinavir, Saquinavir)
- Monoclonal Antibody (Daclizumab, Rituximab)
- Antineoplastics (Interferon alfa-2a, Pegaspargase)
- Selective Serotonin Reuptake Inhibitors (e.g. Paroxetine)
- Tricyclic Antidepressants
- Angiotensin Receptor Blockers (e.g. Losartan)
- Selective Estrogen Receptor Modulators (Tamoxifen)
- Gonadotropin-Releasing Hormone Agonist
- Antiandrogens
- Hypoglycemic agents (Oral Hypoglycemics, Insulin)
- Efavirenz (Sustiva)
-
Drugs of Abuse
- Alcohol Abuse or Alcohol Withdrawal
- Tobacco Abuse
- Heroin Abuse and Withdrawal
- Miscellaneous Causes
V. Differential Diagnosis
- Vasomotor Symptoms of Menopause
- Anxiety Disorder (e.g. Panic Attacks, PTSD)
- Obesity
- Diabetes Mellitus
- Gastroesophageal Reflux Disease
- Environmental Factors
- Excessive heat exposure
- Inadequate heat dissipation (e.g. excessive bedding)
VI. History
- Infectious disease exposure
- Febrile Illness
- Mononucleosis
- Tuberculosis
- HIV Infection (esp. AIDS and opportunistic infections including Pneumocystis, Mycobacterium Avium Complex)
- Endocarditis (ask about IV Drug Abuse)
- Tick Borne Illness (e.g. Lyme Disease)
- Travel History
- Endocrine symptoms
- Menopause (Amenorrhea)
- Andropause (e.g. Erectile Dysfunction)
- Hyperthyroidism symptoms (anxiety, Diarrhea, Tremor, weight loss, Palpitations)
- Hypoglycemia symptoms
- Habits
- High sugar, high fat diet is associated with increased Night Sweats
- Mediterranean Diet in contrast is associated with decreased Night Sweats
- Substance Use associated with Night Sweats
- Tobacco Abuse
- Alcohol use >3 drinks per day
- IV Drug Abuse (e.g endocarditis, Drug Withdrawal)
- High sugar, high fat diet is associated with increased Night Sweats
- Full Review of Systems for comorbid conditions
- Evaluate for causes above
- GERD Symptoms (e.g. Bitter or Metallic Taste on awakening)
- Obstructive Sleep Apnea symptoms (snoring, witnessed apneas)
- Carcinoid Tumor Symptoms (attacks of Abdominal Pain, watery Diarrhea, Flushing, Hypotension)
VII. Exam: Focused on suspected causes
- Body Weight
- Evaluate for Unintentional Weight Loss >5% in the past 6-12 months
- Cachexia suggests severe prolonged weight loss
-
Vital Signs
- Temperature
- Follow Prolonged Fever protocol fo persistent or Recurrent Fever
- Blood Pressure
- Temperature
- Head and Neck Exam
- Thyromegaly (associated with Exophthalmos, Tremor, Tachycardia) may be seen with Hyperthyroidism
- Localized or Generalized Lymphadenopathy (esp. if present >4-6 weeks)
- Oral Candidiasis (e.g. HIV Infection or AIDS)
- Large neck circumference >16-17 cm or Mallampati Score 3-4 are risks for Obstructive Sleep Apnea
- Cardiopulmonary Exam
- New Heart Murmur (e.g. Endocarditis)
- Weak Pulses (Takayasu Arteritis)
- Abdominal Exam
- Splenomegaly (e.g. Mononucleosis, Lymphoma)
- Skin Changes
VIII. Labs
- First-line testing
- Complete Blood Count (CBC)
- Chest XRay
- Mono Spot (consider EBV titers)
- Purified Protein Derivative (PPD) or Quantiferon for Tuberculosis
- Thyroid Stimulating Hormone
- HIV Test
- C-Reactive Protein
- Second-line tests to consider
- Blood Cultures (3 sets) if documented nocturnal fever spikes
- Include atypicals (e.g. Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
- Tick Borne Illness testing (e.g. Lyme Disease, Babesiosis, Anaplasmosis)
- Peri-Menopause Confirmation (Follicle Stimulating Hormone, Anti-Mullerian Hormone)
- Bone Marrow Biopsy if suspected myeloproliferative or lymphoproliferative disorder
- Blood Cultures (3 sets) if documented nocturnal fever spikes
IX. Imaging
- First-Line Imaging
- Second-Line Imaging
X. Evaluation
- Step 1
- Evaluate for causes suggested by history and exam
- Confirm up-to-date cancer screening appropriate for gender, age and risk factors
- Encourage patient to keep a symptom diary along with measured Temperature
- Empiric treatment for 4-8 weeks if likely cause identified by history and exam
- Proton Pump Inhibitor and lifestyle management trial for Esophageal Reflux
- Tobacco Cessation and Alcohol cessation (or decrease)
- Decrease or eliminate specifric medication causes
- Manage Anxiety Disorder
- Step 2
- Perform lab testing and first-line imaging as above
- Step 3
XI. Management
- See Vasomotor Symptoms of Menopause
- Treat specific causes (see evaluation and causes as above)
XII. Prognosis
- Peristent Night Sweats in age >65 years is NOT associated with increased mortality (at least in prmary care)