Night sweats - red flag symptoms - GP online
Night sweats are not a common problem, but may be discovered when exploring other concerns or on a systemic review.
Red flag symptoms
- Significant unintentional weight loss
- Any symptoms warranting a two-week wait referral (see cancer risk assessment tools)
- A history of foreign travel
- Risk factors for HIV
- Palpable lymph glands
- Risk factors for TB
- Recurrent bacterial infections requiring antibiotics
- History of alcohol excess or recreational drug use
- Signs of meningeal irritation (meningism), such as neck stiffness, photophobia, headache
- Haemoptysis
- Symptoms suggestive of COVID-19, such as cough, anosmia, dysgeusia
- Persistent nose bleeds, bleeding gums or petechiae
Differential diagnoses
There are a broad range of differential diagnoses to consider.
Night sweats can be a nonspecific problem, so establishing a cause can be difficult. It is important to find out what the patient means by night sweats and explore what effect they are having. Night sweats requiring patients to change clothing or bed linen should be taken seriously.
Night sweats can be a manifestation of simple infection, underlying malignancy, more complex infections – including TB and HIV – connective tissue disorders, menopause or certain prescribed drugs. It's also important not to overlook possible psychological causes, such as night terrors secondary to PTSD.
Questions to ask
Acute night sweats are more likely to feature in infective pathology so, in this circumstance, you may wish to consider a full systemic review unless the patient volunteers relevant information early on within the consultation.
Useful questions to ask include:
- How long have the night sweats been a problem?
- How much do they bother you?
- What do you feel the problem could be?
- Have you noticed any appetite loss or weight loss?
- Have you had any unexplained persistent fever?
- Have you measured your temperature during the episodes? If so, what is it?
- Have you had any other symptoms, such as persistent cough, dyspnoea, haemoptysis, change in bowel habit, rectal bleeding, haematuria, joint stiffness, swelling or deformity, lumps suggestive of lymph nodes, breast lumps, testicular lumps or postmenopausal bleeding (if relevant)?
- Have you had any urinary symptoms? (Specifically useful to ask older male patients)
- Are there any new or changing skin lesions?
- How much alcohol do you drink and do you use recreational drugs?
- Do you smoke? (This may be relevant if malignancy is suspected, but also may exacerbate the symptom).
- Are you experiencing any depressive or anxiety-type symptoms?
- Do you have any symptoms of COVID-19?
In addition to the questions above, if you suspect that your patient is menopausal, then consider asking about other vasomotor symptoms, such as hot flushes, urogenital symptoms, such as vaginal dryness, or mood disturbance.
As lymphadenopathy can affect the neck, axilla and inguinal region, you should ask about swelling in these specific areas.
Ensure you are familiar with the patient's medications. Certain medications can cause hot flushes, for example hormonal treatments for prostate cancer.
It may be important to know if the patient has a history of foreign travel if TB or another infectious disease is suspected. Consider HIV if there are risk factors for this (including blood transfusions, IV drug use, tattoos or same-sex partners).
Possible causes
Possible causes include:
- Simple infection, such as ENT infection or respiratory tract infection
- Malignancy, such as leukaemia or lymphoma
- Complex infections, such as TB, HIV
- Menopause
- Prescribed drugs, for example, hormonal treatments for prostate cancer
- Anxiety
- COVID-19
- Obesity
- Endocrine causes, such as pheochromocytoma or autonomic disturbance secondary to diabetes
Examination
Examination will be guided by your history.
Remote examination via telephone
- Does the patient sound unwell?
- Is there any respiratory distress?
- Can the patient check their pulse, blood pressure or oxygen saturation for you, if relevant?
- Can they provide you with a weight, if relevant?
Remote examination via video
- How does the patient look?
- Are they in any distress?
- Do they appear cachectic?
- Can the patient check their pulse, blood pressure or oxygen saturation for you, if relevant?
- Are there any relevant lesions they can show you? For example, skin lesions, tongue lesions, new lumps?
Face-to-face examination
- For face-to-face examinations, ensure you wear appropriate PPE.
- If appropriate, check the patient's temperature. Do they look cachectic? It may be useful to weigh them.
- If malignancy is suspected, examination of the affected system will be necessary. Auscultate and percuss the chest to exclude evidence of pneumonia or effusion. Check the abdomen for masses, for example hepatosplenomegaly. It may also be necessary to check palpable lymph nodes, for example cervical, axillary or inguinal nodes.
Investigations
Investigations will be guided by the history and examination findings. The list below is not exhaustive.
Primary care investigations may include:
- Routine blood tests - FBC, U&Es, LFTs, CRP, ESR, HIV, TSH, autoimmune screen, VDRL (syphilis screening test), FSH LH, HbA1c, and monospot test for glandular fever
- FIT testing
- 24-hour urinary catecholamines, urine for MSU as well as for for chlamydia/gonorrhoea
- COVID-19 PCR testing
- Sputum culture and sensitivity
- Stool cultures may be relevant. If you suspect infective diarrhoea as a cause, you may require three samples on three separate days to increase the likelihood of catching the infection
- Plain chest X-ray
- Ultrasound of the abdomen and pelvis may be necessary
- Ultrasound soft tissue if you find lymph nodes (as well as ultrasound of any other area of concern)
- HADS score if you suspect anxiety
- You might have direct access to CT scanning, which may be relevant.
Other investigations, such as MRI or bone scans, may require secondary care referral via the appropriate pathway. More complex elderly patients may require referral to rapid access elderly care service. Testing for tumour markers is not recommended in primary care.
Any red flag symptoms may require appropriate investigations under the two-week rule, depending on the rest of the history, examination findings and preliminary investigations.
Pyrexia of unknown origin may require assessment by your local infectious diseases team.
Management will largely depend on the cause of the problem.
- Dr Singh is a GP in Northumberland
Take a test on this article and claim your certificate on MIMS Learning
This is an updated version of an article first published in August 2013, updated in 2018 and updated again in June 2021.
Comments
Post a Comment