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Approach to Night Sweats

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

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  1. Approach to Night Sweats Jeffrey P Schaefer, MD January 10, 2007

  2. Objectives • Definition • Frequency • Differential Diagnosis • Work-up

  3. What do we actually know? Not much

  4. Nothing

  5. Incidental References to Night Sweats

  6. Nothing

  7. Nothing Useful

  8. 1 sentence “Night sweats may accompany an elevated temperature at night.”

  9. Lay Internet • 8 causes of night sweats • buy some Ensure

  10. Lay Internet ‘Avoid alcohol and spicy food’ - buy a gadget

  11. 682 hits • majority are disease oriented • case reports • little quantitative data • no ‘economic analyses’ • no ‘comparison of diagnostic strategy’

  12. Reference 1 Am Fam Phys 2003;67:1019-24

  13. Reference 2 www.uptodate.com October, 2005

  14. 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

  15. 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)

  16. What makes us sweat? • Glands • eccrine (generalized - watery) • apocrine (perianal / genital - sialomucin) • apoeccrine (axillae - hybrid) • Stumuli • thermoregulatory sweating • emotional sweating • gustatory sweating

  17. 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

  18. 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

  19. 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

  20. Pure Night Sweats: 20 – 25% Day and Night Sweats: Men ~15% Women 25% Any night sweats ~40%

  21. 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

  22. Pure Night Sweats All: Panic Attacks Men: Sleep Problems Women: Hot Flashes & Panic Attacks

  23. Day and Night Sweats hot flashes chronic infection sleep problems TCA Xanthines Other Anti-depressants Weight Anti-histamines Alcohol

  24. Differential Diagnosis

  25. Differential Diagnosis

  26. 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

  27. Clinical Evaluation Journal Article… “Thorough history and physical examination”

  28. Diagnostic Work-upAm Fam Pract 2003 • Like any diagnostic regimen… • depends on pre-test probability of disease!

  29. 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.

  30. 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?)

  31. 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

  32. 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

  33. 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

  34. 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

  35. Friend / Foe: Time • Neoplasms • Inflammatory Disease • Infectious Diseases • Improbable that these will not ‘come to light’ after 6 – 12 months.

  36. 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

  37. Therapies • Empiric trial for GERD… • Eliminate unnecessary medication • good time to stop the sed / hypnotic • No alcohol for 4 – 8 weeks • Food elimination trial?

  38. 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

  39. No conflicts to declare • Thank you for your time Questions? Experiences to share?

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