Approach to the patient with night sweats
- Gerald W Smetana, MD
Gerald W Smetana, MD
- Professor of Medicine
- Harvard Medical School
Night sweats are a common symptom in ambulatory primary care practice. While the cause may be evident after straightforward history taking, often no cause is immediately apparent. In these cases, clinicians face the challenge of determining a thoughtful, cost effective, yet comprehensive evaluation.
The definition and epidemiology of night sweats, differential diagnosis, approach to history taking and physical examination, and suggested evaluation of the patient with night sweats are discussed here. The management of benign excessive sweating (idiopathic hyperhidrosis) is discussed separately. (See "Primary focal hyperhidrosis".)
Night sweats must be distinguished from other disorders of sweating. For the purposes of this discussion, night sweats are drenching sweats that require changing bedclothes. This more strict definition excludes patients with a benign increase in sweating, or hyperhidrosis. An overheated room or too many bed coverings may be a simple cause for an increase in sweating at night.
Hot flashes are often difficult to distinguish from night sweats, although the former have several distinctive features. Hot flashes may begin with an unpleasant sensation in the chest, breasts, or abdomen. A sudden warmth, and visible skin redness in the chest, head, and neck follows, which may be apparent to observers . The warmth lasts for three to four minutes and is followed by sweating in the same areas. (See "Menopausal hot flashes".)
Flushing, a feature of carcinoid and an adverse effect of certain medications, is a warmth and redness of the face and occasionally the trunk. In practice, it may be difficult to distinguish flushing or increased sweating from night sweats. Thus, the conditions associated with any of these symptoms are discussed below.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kenemans P. Menopause, HRT and menopausal symptoms. J Epidemiol Biostat 1999; 4:141.
- Lea MJ, Aber RC. Descriptive epidemiology of night sweats upon admission to a university hospital. South Med J 1985; 78:1065.
- Quigley CS, Baines M. Descriptive epidemiology of sweating in a hospice population. J Palliat Care 1997; 13:22.
- Reynolds WA. Are night sweats a sign of esophageal reflux? J Clin Gastroenterol 1989; 11:590.
- Mold JW, Mathew MK, Belgore S, DeHaven M. Prevalence of night sweats in primary care patients: an OKPRN and TAFP-Net collaborative study. J Fam Pract 2002; 51:452.
- Mold JW, Lawler F. The prognostic implications of night sweats in two cohorts of older patients. J Am Board Fam Med 2010; 23:97.
- Lister TA, Crowther D, Sutcliffe SB, et al. Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin's disease: Cotswolds meeting. J Clin Oncol 1989; 7:1630.
- Miller LG, Asch SM, Yu EI, et al. A population-based survey of tuberculosis symptoms: how atypical are atypical presentations? Clin Infect Dis 2000; 30:293.
- Guler SA, Bozkus F, Inci MF, et al. Evaluation of pulmonary and extrapulmonary tuberculosis in immunocompetent adults: a retrospective case series analysis. Med Princ Pract 2015; 24:75.
- Aktoğu S, Yorgancioglu A, Cirak K, et al. Clinical spectrum of pulmonary and pleural tuberculosis: a report of 5,480 cases. Eur Respir J 1996; 9:2031.
- Van den Brande P, Vijgen J, Demedts M. Clinical spectrum of pulmonary tuberculosis in older patients: comparison with younger patients. J Gerontol 1991; 46:M204.
- Cohen R, Muzaffar S, Capellan J, et al. The validity of classic symptoms and chest radiographic configuration in predicting pulmonary tuberculosis. Chest 1996; 109:420.
- Corbett EL, Zezai A, Cheung YB, et al. Provider-initiated symptom screening for tuberculosis in Zimbabwe: diagnostic value and the effect of HIV status. Bull World Health Organ 2010; 88:13.
- Alavi-Naini R, Cuevas LE, Squire SB, et al. Clinical and laboratory diagnosis of the patients with sputum smear-negative pulmonary tuberculosis. Arch Iran Med 2012; 15:22.
- Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005; 352:2325.
- Cunningham WE, Shapiro MF, Hays RD, et al. Constitutional symptoms and health-related quality of life in patients with symptomatic HIV disease. Am J Med 1998; 104:129.
- Bollinger RC, Brookmeyer RS, Mehendale SM, et al. Risk factors and clinical presentation of acute primary HIV infection in India. JAMA 1997; 278:2085.
- Hofer CB, Harrison LH, Struchiner CJ, et al. Acute retrovirus syndrome among prospectively identified homosexual men with incident HIV infection in Brazil. Projecto Praça Onze Study Group. J Acquir Immune Defic Syndr 2000; 25:188.
- Cheshire WP, Fealey RD. Drug-induced hyperhidrosis and hypohidrosis: incidence, prevention and management. Drug Saf 2008; 31:109.
- Trindade E, Menon D, Topfer LA, Coloma C. Adverse effects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: a meta-analysis. CMAJ 1998; 159:1245.
- Goldstein RE, O'Neill JA Jr, Holcomb GW 3rd, et al. Clinical experience over 48 years with pheochromocytoma. Ann Surg 1999; 229:755.
- Noshiro T, Shimizu K, Watanabe T, et al. Changes in clinical features and long-term prognosis in patients with pheochromocytoma. Am J Hypertens 2000; 13:35.
- Vinik AI, McLeod MK, Fig LM, et al. Clinical features, diagnosis, and localization of carcinoid tumors and their management. Gastroenterol Clin North Am 1989; 18:865.
- Spaulding SW, Lippes H. Hyperthyroidism. Causes, clinical features, and diagnosis. Med Clin North Am 1985; 69:937.
- Trop CS, Bennett CJ. The evaluation of autonomic dysreflexia. Semin Urol 1992; 10:95.
- Lee BY, Karmakar MG, Herz BL, Sturgill RA. Autonomic dysreflexia revisited. J Spinal Cord Med 1995; 18:75.
- Glasauer FE, Czyrny JJ. Hyperhidrosis as the presenting symptom in post-traumatic syringomyelia. Paraplegia 1994; 32:423.
- Korpelainen JT, Sotaniemi KA, Myllylä VV. Hyperhidrosis as a reflection of autonomic failure in patients with acute hemispheral brain infarction. An evaporimetric study. Stroke 1992; 23:1271.
- Schulz V, Ward D, Moulin DE. Segmental hyperhidrosis as a manifestation of spinal and paraspinal disease. Can J Neurol Sci 1998; 25:325.
- von Mühlen DG, Kritz-Silverstein D, Barrett-Connor E. A community-based study of menopause symptoms and estrogen replacement in older women. Maturitas 1995; 22:71.
- Avis NE, Stellato R, Crawford S, et al. Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups. Soc Sci Med 2001; 52:345.
- Sievert LL, Obermeyer CM, Price K. Determinants of hot flashes and night sweats. Ann Hum Biol 2006; 33:4.
- Hunter MS, Gentry-Maharaj A, Ryan A, et al. Prevalence, frequency and problem rating of hot flushes persist in older postmenopausal women: impact of age, body mass index, hysterectomy, hormone therapy use, lifestyle and mood in a cross-sectional cohort study of 10,418 British women aged 54-65. BJOG 2012; 119:40.
- Avis NE, McKinlay SM. The Massachusetts Women's Health Study: an epidemiologic investigation of the menopause. J Am Med Womens Assoc (1972) 1995; 50:45.
- Leung AK, Chan PY, Choi MC. Hyperhidrosis. Int J Dermatol 1999; 38:561.
- Mold JW, Woolley JH, Nagykaldi Z. Associations between night sweats and other sleep disturbances: An OKPRN study. Ann Fam Med 2006; 4:423.
- Arnardottir ES, Janson C, Bjornsdottir E, et al. Nocturnal sweating--a common symptom of obstructive sleep apnoea: the Icelandic sleep apnoea cohort. BMJ Open 2013; 3.
- Mold JW, Goodrich S, Orr W. Associations between subjective night sweats and sleep study findings. J Am Board Fam Med 2008; 21:96.
- Morris GC, Thomas TP. Night sweats--presentation of an often forgotten diagnosis. Br J Clin Pract 1991; 45:145.
- Raff SB, Gershberg H. Night sweats. A dominant symptom in diabetes insipidus. JAMA 1975; 234:1252.
- Hunt DP, Muse VV, Ly A. Case records of the Massachusetts General Hospital. Case 4-2014. A 39-year-old man with night sweats and abdominal pain. N Engl J Med 2014; 370:467.
- Komaroff AL. Clinical presentation of chronic fatigue syndrome. Ciba Found Symp 1993; 173:43.
- Sheehy TW. Diabetic gustatory sweating. Am J Gastroenterol 1991; 86:1514.
- Laskawi R, Ellies M, Rödel R, Schoenebeck C. Gustatory sweating: clinical implications and etiologic aspects. J Oral Maxillofac Surg 1999; 57:642.
- - Lymphoma
- - Solid tumors
- - Tuberculosis
- - Brucellosis
- - Bacterial infections
- - HIV infection
- - Antidepressants
- - Antipyretics
- - Cholinergic agonists
- - Hypoglycemic agents
- - Hormonal agents
- - Other medications causing flushing
- - Other medications causing sweating
- Endocrine disorders
- - Pheochromocytoma
- - Carcinoid syndrome
- - Hyperthyroidism
- Neurologic disorders
- Idiopathic hyperhidrosis
- Sleep disorders
- Miscellaneous causes
- CLINICAL EVALUATION
- Physical examination
- Diagnostic strategies
- SUMMARY AND RECOMMENDATIONS