Transcript Journal Watch - Schaeferville

Approach to Night Sweats
Jeffrey P Schaefer, MD
January 10, 2007
Objectives
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Definition
Frequency
Differential Diagnosis
Work-up
What do we actually know?
Not much
Nothing
Incidental References to Night Sweats
Nothing
Nothing Useful
1 sentence
“Night sweats may
accompany an elevated
temperature at night.”
Lay Internet
• 8 causes of night sweats
• buy some Ensure
Lay Internet
‘Avoid alcohol and spicy food’
- buy a gadget
• 682 hits
• majority are disease oriented
– case reports
– little quantitative data
• no ‘economic analyses’
• no ‘comparison of diagnostic strategy’
Reference 1
Am Fam Phys
2003;67:1019-24
Reference 2
www.uptodate.com
October, 2005
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
• 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?
• Glands
– eccrine (generalized - watery)
– apocrine (perianal / genital - sialomucin)
– apoeccrine (axillae - hybrid)
• Stumuli
– thermoregulatory sweating
– emotional sweating
– gustatory sweating
Pathophysiology of Night Sweats
• Not much known
• Could speculate:
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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
• 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;51:452-6
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
Pure Night Sweats: 20 – 25%
Day and Night Sweats: Men ~15% Women 25%
Any night sweats ~40%
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
Pure Night Sweats
All: Panic Attacks
Men: Sleep Problems
Women: Hot Flashes & Panic Attacks
Day and Night Sweats
hot flashes
chronic infection
sleep problems
TCA
Xanthines
Other Anti-depressants
Weight
Anti-histamines
Alcohol
Differential Diagnosis
Differential Diagnosis
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
Journal Article…
“Thorough history and physical
examination”
Diagnostic Work-up
Am Fam Pract 2003
• Like any diagnostic
regimen…
• depends on pretest probability of
disease!
JP Schaefer Approach
Given
1. I’ve never diagnosed an new illness that
presented solely with night sweats.
2. The presence of night sweats do not
appreciably alter the probability of any
disease.
3. Patients (and referring physicians)
have expectations.
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
• 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
• Don’t miss…
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weight loss
fever  patient keeps temp diary
hypertension (pheo)
malignant skin lesions
lymphadenopathy
murmurs
abdominal masses
scrotal / prostate / cervix / breast masses
arthritis
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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…
• Think ‘fever of unknown origin’
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Tuberculin
Bone scan
Bone Marrow Aspiration and Biopsy
Gastroscopy / Colonoscopy
CT head  sinusitis
MRI head  Multiple Sclerosis
Friend / Foe: Time
• Neoplasms
• Inflammatory Disease
• Infectious Diseases
• Improbable that these will not ‘come
to light’ after 6 – 12 months.
All Negative… Now what?
1. Educate patients about the
frequency and non-specific nature
of night sweats.
2. Ask patients to monitor for:
-
weight loss
fever (thermometer)
unexplained pain
symptoms of sleep apnea and reflux
3. Reassessment
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
• Night sweats…
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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
• No conflicts to declare
• Thank you for your time
Questions?
Experiences to share?