Evaluation and Management of Night Sweats

Initial Clinical Assessment

The American College of Physicians recommends beginning with thyroid-stimulating hormone (TSH) and free T4 testing, followed by a complete blood count, tuberculosis testing, HIV testing, C-reactive protein, and chest radiography if initial evaluation is unrevealing 1
Menopause status in women is an important historical feature to elicit, as this is the most common cause of night sweats in older women 2
The frequency and severity of episodes, including impact on quality of life, should be assessed 2
Associated symptoms such as weight loss, fever, or fatigue (suggesting infection or malignancy) should be evaluated 2
Symptoms like cold intolerance, dry skin, constipation, hoarseness (hypothyroidism) 1, heat intolerance, nervousness, tremulousness, insomnia, weight loss, diarrhea (hyperthyroidism) 1, and paroxysmal hypertension, headache, palpitations, pallor (pheochromocytoma) 1 should be considered
Prolonged cough with sputum production, hemoptysis (tuberculosis) should be evaluated 3
Risk factors for tuberculosis (immigration from high-prevalence areas, HIV infection, homelessness, incarceration) should be assessed 3

A thyroid examination for goiter, periorbital puffiness, coarse/cold skin, slow movement, delayed ankle reflexes is recommended 1

Primary screening for thyroid dysfunction should include TSH and free T4 testing 1

24-hour urinary fractionated metanephrines or plasma metanephrines should be considered if episodic symptoms with hypertension suggest pheochromocytoma 1
Polysomnography should be considered if obstructive sleep apnea is suspected (present in 25-50% of cases with night sweats) 1

When thyroid dysfunction is suspected, no additional confirmatory tests are needed beyond abnormal TSH and free T4 for diagnosis 1
When menopause is suspected, standardized scales like the Greene Scale should be used to establish severity 1
When tuberculosis is suspected, respiratory cultures via sputum or throat swab should be obtained if cough is present for >2-3 weeks 3
Classic presentation of tuberculosis includes upper lobe infiltrates with cavitation on chest radiograph 3

Non-pharmacological measures such as improving sleep hygiene, avoiding triggers, and considering relaxation techniques should be implemented 2
The combination of night sweats and cold intolerance strongly suggests thyroid dysfunction as the most likely diagnosis 1