Diaphoresis is defined as a profuse sweating which equals to more than one litre of sweat per hour at particular times of the day. Diaphoresis represents the response of the autonomic nervous system to the psychogenic physical stress, high temperature, fever and physical insult.
An individual who is anxious may suffer from diaphoresis /excessive sweating that is limited to the forehead, soles and palms. Generalized sweating is common in high temperature or during fever. Psychogenic /physical stress may cause generalized sweating as well as limited but profuse sweating in the soles, palms and forehead.
Diaphoresis may initially present abruptly and accompanied by other signs such as high blood pressure/hypertension and tachycardia. (The stimulation of the autonomic system).
Intermittent diaphoresis is associated with a chronic disorder that is presented with recurrent fever. Episodes of acute pain or fever may be presented with localized diaphoresis. Intermittent fever is characterized by night sweat as the temperature of the body will return to normal at 2am to 4am before the temperature start to rise again.
Hot flushes or sensation of intense heat during menopause which follow by diaphoresis is common among women. The patient may also sweat profusely in cases such as during exertion, exercise, or during mild to moderate anxiety as these situations may trigger the fight or flight response, accelerating the metabolism process and creating an internal heat.
Exposure to the high temperature also may lead to diaphoresis. Several days are required for acclimatization to take place due to exposure to high temperature. The normal body temperature will be maintained by diaphoresis during this time period.
Common causes of diaphoresis may not affect infant and small children as the sweat gland is not properly develop and immature.
A patient who complains of diaphoresis should be assessed carefully to rule out any life threatening condition. The patient should be asked about any symptoms of palpitation, dizziness, change in hearing, vision, headache, insomnia, generalized weakness, fatigue, nausea, vomiting, difficulty breathing, cough, sputum, altered bowel habits, , altered bladder habits or pleuritic pain. Additional questions may include asking the patient about any recent travels, weight gain or weight loss, stiffness m muscle cramps, joint pain, paraesthesia, recent exposure to chemical such as pesticides, change in the sizes of the shoes or gloves lately, history of alcohol or drug abuse or history of partial gastrectomy.
A question such as identifying the menopause or non menopause status of the woman is also important as well as any changes in the menstrual cycles.
The physical examination may include inspecting the patient’s bed and clothing to detect whether diaphoresis occur during the day or night. The forehead, palm, soles extremities as well as the trunk are inspected to identify the extent of diaphoresis. Increases in the amount of the coarse body hair, a lesion in the skin or flushing and abnormal skin texture are inspected. The present of dry mucous membrane or poor skin turgor is observed.
The patient’s nail is observed. Look for any evidence of Plummer’s nail. What is Plummer‘s nail? Plummer’s nail is presented with the separation of the ends of the fingernail from the nail beds. The patient is observed for the present of any flaccid paralysis or fasciculations. Vital signs are taken and the patient‘s mental status is observed. The patient’s eyes are examined and look for any excessive tearing, pupillary constriction, pupillary dilation or exophthalmos. Visual field of the patient is tested. We should stay alert about the possibilities of seizures and observe the facial expression of the patient. Any gum or tooth disease should be documented and check for the patient’s hearing status. Any hearing loss should be noted. The lymph node, liver and spleen are palpated to look for any evidence of lymphadenopathy or hepatosplenomegaly. Examination of the lung is performed. Auscultate the lung and look for any evidence of diminished in breath sound, bronchial breathing, crackles and increase in vocal fremitus. Dullness of the lung may be detected by percussion.
There are a lot of the causes of diaphoresis. These may include lung abscess, infective endocarditis, tuberculosis, thyrotoxicosis, tetanus, pneumonia, hypoglycaemia, Hodgkin’s disease, pheochromocytoma, myocardial infarction, heat exhaustion, anxiety disorder, heart failure, autonomic hyperrelfexia and acromegaly.
The signs and symptoms of lung abscess are productive cough with copious purulent bloody sputum, weakness, weight loss, anorexia, headache, dyspnea, pleuritic chest pain, fever, chills, dullness chest percussion, amphoric or tubular breath sound, clubbing, malaise and drenching night sweat.
Besides generalized early night sweat, subacute infective endocarditis may also present with arthralgia, anorexia, weight loss, fatigue, weakness and intermittent low grade fever. Other classical signs of infective endocarditis may also present such as splinter haemorrhage or the discovery of a new murmur or sudden changes in the murmur or petechiae.
In primary infection, tuberculosis is mostly appear to be asymptomatic. The only signs or symptoms that present may include low grade fever, night sweat, weight loss, anorexia, weakness and fatigue. Chest pain, hemoptysis and muco purulent sputum with productive cough are common in the reactivation stages of tuberculosis.
Diaphoresis is common with thyrotoxicosis. The other signs and symptoms of thyrotoxicosis may include nervousness, heat intolerance, tremor, tachycardia, palpitation, increased in appetite, dyspnea, enlargement of the thyroid gland, exophthalmus and Plummer’s nail as we as gallop rhythm while auscultating the heart.
Low grade fever, hyperactive deep tendon reflex, tachycardia and profuse sweating are commonly associated with tetanus. Initially the patient may appear restless, which progress to stiffness and pain in the back, abdomen and jaw which later develop into spasm, lock jaw, opisthotonus, risus Sardonicus and dysphagia. Sudden death by asphyxiation or cyanosis may occur as a result of laryngospasm.
Pneumonia is suspected in patients who suffers from fever, chills and intermittent generalized diaphoresis. Patient complains of pleuritic sharp pain which is worse on movement as well as during deep inspiration. Other features may include fatigue, abdominal pain, cyanosis, anorexia, myalgia, headache, mucoid, scant or purulent copious sputum , productive cough, dyspnea, tachypnea and the present of bronchial breath sound.
The signs and symptoms of hypoglycemia may include hunger, hypotension, tremor, irritability, blurred vision, loss of consciousness, tachycardia and may lead to diaphoresis if rapidly induced.
Night sweats is one of the early signs of Hodgkin’s disease. Other features may include weight loss, pruritus, fatigue and fever. Hodgkin’s disease initially presents with painless swelling of the cervical lymph nodes. The patient may present with periods of afebrile and chills for several days or weeks. This is known as Pel - Ebstein fever pattern. Symptoms such as night sweat, fever and weight loss carries a poor prognosis. Widespread effect such as hepatomegaly and dyspnea may occur due to progressive lymphadenopathy.
Pheochromocytoma is a hormonal disturbance that presents with diaphoresis, headache, tachycardia, palpitations, tremor, anxiety, pallor, paraesthesia, flushing, abdominal pain, nausea, vomiting, tachypnea and intermittent or paroxysmal hypertension as well as orthostatic hypotension.
Diaphoresis which is accompanied by substernal radiating chest pain that is acute in onset is a sign of myocardial infarction. Myocardial infarction is a life threatening condition. The associated signs and symptoms of myocardial infarction may include pallor clammy skin, fine crackles on auscultation, changes in blood pressure, irregular pulse, tachycardia, dyspnea, anxiety and nausea and vomiting.
Heat exhaustion is associated with anxiety, weakness and profuse sweating as a result of failure of the heat to dissipate. The condition may progress to shock ( cold, clammy skin, tachycardia, hypotension, thready pulse and confusion) and circulatory collapse. The patient may also present with ashen grey appearance as a well as dilated pupils.
Anxiety disorder is divided into acute anxiety disorder and chronic anxiety disorder. Panic is the most common presenting symptoms of acute anxiety. Symptoms such as obsessive compulsive disorder, phobias and conversion disorders are common with chronic anxiety disorder. The anxiety disorder generally may lead to sympathetic stimulation which leads to diaphoresis. The diaphoresis mostly present on the forehead, soles and palms. It is accompanied by gastrointestinal distress, tremor, tachycardia, tachypnea and palpitation. Behaviour changes fear and difficulty to concentrate which are the physiological symptoms may also happen.
Left sided heart failure is presented with orthopnea, dyspnea and fatigue as well as tachycardia. Right sided heart failure is presented with dry cough and distended neck vein. The right sided heart failure and left sided heart failure are usually preceded with diaphoresis. Besides diaphoresis, patients may present with anxiety disorder, dependent edema, ventricular gallop, crackles, cyanosis and tachypnea.
Any injury to the spinal cord above the level of T6 may result in spinal shock. The resolution of the spinal shock may result in autonomic hyperreflexia. Autonomic hyperreflexia may cause a dramatic increase in blood pressure, blurred vision, pounding headache and profuse sweating. Diaphoresis/profuse sweating usually occur above the level of the injury especially in the forehead. The diaphoresis is accompanied by flushing, bradycardia, nasal congestion, nausea and restlessness.
In acromegaly, diaphoresis is a sensitive indicator of the severity of the disorder. Acromegaly is a slow progressive hormonal disorder which leads to an increase in the metabolic rate as a result from hyper secretion of the growth hormone. Patient presented with enlarged jaw, feet and hand, oily, thickened, warm skin, pain in the joint, hoarseness, weight gain, increase coarse body hair, severe headache, blindness, visual field deficit, hypertension, thickened ears, nose, enlarged supraorbital ridges, hulking appearance, thickened heel pads and thickened nose and ears.
Diaphoresis may also be associated with pesticide poisoning. The patient may present with flaccid paralysis, muscle weakness, fasciculations, excessive salivation and lacrimation, miosis, blurred vision, diarrhoea, nausea and vomiting. Coma and respiratory arrest are the late presenting signs.
Dumping syndrome may cause diaphoresis. Dumping syndrome occurs in patient with partial gastrectomy. It is caused by rapid emptying of gastric content into the small intestine. The patient may present with epigastric tenderness, weakness, palpitation, diarrhoea, nausea and diaphoresis.
There are a few drugs that may cause diaphoresis. The drugs are antipyretics, sympathomimetic, thyroid hormones, selective antipsychotic and acetaminophen and aspirin poisoning.
In small children and infants diaphoresis is mostly prominent around the head due to overdressing or environmental heat. Withdrawal of drugs related to heart failure, thyrotoxicosis, or maternal addiction may cause diaphoresis. Drugs such as thyroid hormones, haloperidol, ephedrine and antihistamine may also lead to diaphoresis.
Elderly patients may have a decrease sweating mechanism and they may not show any sign of diaphoresis. This condition puts them at risk of developing heat strokes in high temperature. Diaphoresis may only happen if there is a change in weight and activity.
A patient presenting with differential should be prepared with blood tests, immunological test, cultures, chest X ray, CT scans, audiometry and biopsy
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