Dr. Huntley's
Diagnosis
Checklist
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Diaphoresis
❑ Fever
❑ Hot flashes
❑ Anxiety
❑ Drugs
❑ Gustatory
❑ Thyrotoxicosis
❑ Parkinson disease
❑ Autonomic neuropathy
❑ Central neurologic injury
❑ Pheochromocytoma
❑ Carcinoid
❑ Acromegaly
Night Sweats
❑ Malignancy
❑ Lymphoma
❑ Tuberculosis
❑ HIV
❑ Bacterial endocarditis
❑ Osteomyelitis
❑ Pyogenic abscess
❑ Drugs
❑ Nocturnal hypoglycemia
Eccrine glands are concentrated on the palms, soles, face, and axilla. They function to cool the body through evaporation. They are under cholinergic control and may be stimulated by epinephrine. Apocrine glands are associated with hair follicles in the axilla and groin. Their secretions are viscid and produce an odor after acted on by bacteria.
Measuring the temperature during diaphoresis helps to determine whether a fever is present, which suggests infection.
Night sweats are distinguished as drenching sweats that require changing the bedclothes. “Night sweats of unknown origin” have a differential similar to “fever of unknown origin.”
Excessive sweating with vasoconstriction (cold and clammy skin) may be caused by insulin hypoglycemia, dumping syndrome, drug withdrawal, shock, vasovagal states, or intense pain.
Fever Usually caused by infection, sweating is prominent during defervescence, especially at night. Consider occult infections such as HIV, granulomatous disease, or endocarditis when localizing symptoms are not evident.
Hot flashes Hot flashes usually produce objective flushing in the chest and face, followed by sweating. Other signs of perimenopause, such as irregularities in menstrual cycle length or flow are key clues.
Anxiety Characteristically, sweating occurs on the palms and soles (eccrine).
Drugs Sweating occurs with antipyretics (fever lysis), insulin-induced hypoglycemia, tricyclic antidepressants, and withdrawal of addictive drugs (alcohol, opiates, depressants). Niacin, tamoxifen, sildenafil, nitroglycerin, hydralazine, and bromocriptine may cause flushing and sweats.
Gustatory Typically, sweating induced by spicy food occurs on the face, especially the upper lip.
Thyrotoxicosis Signs of a hypermetabolic state (e.g., tachycardia) are present with or without findings of Graves disease (stare, lid lag, fine tremor, thyromegaly). The sweating will not be paroxysmal.
Parkinson disease There is an increase in both sweating and sebaceous activity, associated with masked facies, cyclical hand tremor, and shuffling gait with en-bloc movements.
Autonomic neuropathy Concomitant orthostatic hypotension is usually present.
Central neurologic injury Stroke or tumor may cause sweating. Examine the eye grounds for papilledema, and look for focal neurological signs, which are usually obvious. A unilateral increase in sweating can occur following acute hemispheric stroke, and segmental hyperhidrosis may occur with a spinal or paraspinal lesion.
Pheochromocytoma Paroxysms of sympathetic hyperactivity (acute blood pressure elevation and flushing) occur in a patient with evidence of a hypermetabolic state (e.g., weight loss).
Carcinoid Episodic flushing, wheezing, and diarrhea are typical.
Acromegaly The handshake is characteristic: moist, warm, doughy. The hands, jaw, and tongue are enlarged, with frontal bossing. Compare the current appearance with old photographs.
Malignancy Common malignancies with associated night sweats include renal cell cancer, prostate cancer, and germ cell tumors. Medullary carcinoma of the thyroid can produce sweats via calcitonin secretion, and insulinoma via nocturnal hypoglycemia.
Lymphoma Drenching night sweats with fever is a frequent presenting symptom complex especially in Hodgkin lymphoma (up to 25% of cases). A PelEbstein pattern of relapsing fever of 3 to 10 days duration with a 3 to 10 day afebrile interlude is seen in 16%. Other clues include pruritis and pain with alcohol consumption.
Tuberculosis Sweats occur in 50% of cases, often recurring over more than 2 weeks. They are more common in patients with extrapulmonary disease. Other manifestations include productive cough, fatigue, and weight loss. Suspect tuberculosis in high-risk patients such as HIV-infected persons, homeless persons, recent Southeast Asian immigrants, or Native Americans.
HIV Night sweats occur in 70% of patients with symptomatic HIV infection. They may be caused by the HIV infection itself, or may be secondary to immunosuppression, with infection by mycobacterium avian-complex
toxoplasma, cytomegalovirus, mycobacterium tuberculosis, pneumocystis, cryptococci, histoplasma, or to non-Hodgkin lymphoma, or drug fever.
Bacterial endocarditis A new heart murmur is a telling finding. Examine the patient carefully for splinter hemorrhages, splenomegaly, conjunctival petechiae, or tender nodules on the hands (Osler nodes).
Osteomyelitis Subacute in onset, there is dull, constant pain and soft tissue swelling/tenderness over the involved bone, with low-grade fever.
Pyogenic abscess Look for localizing symptoms, most commonly pain. Dental abscess, sinusitis, and prostatitis are frequent occult causes.
Nocturnal hypoglycemia Suspect in a diabetic on insulin or oral hypoglycemics, especially when newly started. Look for associated tremor and confusion. A fingerstick glucose will be low, and the symptoms will resolve with food.
Read excerpts from these other book chapters related to Sweating:
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5 
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