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Don’t sweat the small stuff
Patients with hyperhidrosis should not cause you to perspire.
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A 57-year-old man is referred by his primary care provider for an evaluation of hyperhidrosis. Symptoms started approximately 10 years before the visit, are profuse and generalized, are independent of exertion, and also occur at night. Episodes can last a few minutes or hours.
The patient also reports heat intolerance. He denies headaches, anxiety, palpitations, wheezing, diarrhea, headaches, facial edema, flushing or pallor. He also denies exercise intolerance, fatigue, weight changes, cold intolerance, bowel or skin changes, nervousness, jitteriness, labile mood, hair loss, multiple daily bowel movements or goiter. Past medical history consists of untreated obstructive sleep apnea, mild chronic obstructive pulmonary disease, hypertension, hypercholesterolemia and obesity.
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Past surgical history is remarkable for appendectomy. Medications consist of lisinopril 10 mg daily, simvastatin 80 mg nightly, acetylsalicylic acid 81 mg daily, fluticasone (Flovent HFA, GlaxoSmithKline) 110 mcg two puffs by mouth two times per day and no nutritional supplements. There are no known allergies.
The patient has never smoked and has three alcoholic drinks per week. He is an IT manager. Family history is noncontributory.
Pertinent positives on physical exam: blood pressure 110 mm Hg/78 mm Hg, pulse 80, temperature 98.6°F (37.0°C), weight 316 lb (143 kg). No acute distress, obese with plethora. Cardiovascular, pulmonary and abdominal exam are normal. There is no tremor. The patient displays normal judgment and insight, normal mood/affect and is nonanxious. He has no rashes, and his skin is warm and moist.
What is the best next step in the workup and management of this patient with long-standing sweating?
A. Test 24-hour urine metanephrines.
B. Refer the patient for endoscopic thoracic sympathectomy.
C. Administer two-hour oral glucose tolerance test with insulin levels and C-peptide.
D. Ask the patient to keep a food diary and inquire about caffeine-containing beverages.
E. Assess morning testosterone profile and estradiol levels.
Case Discussion:
Answer: D
This is a 57-year-old obese man who presents for long-standing sweating, a “standard” in every endocrinologist’s practice. There are myriad reasons for hyperhidrosis with and without flushing, including hundreds of drugs, drug interactions and nutritional supplements; infectious and immunologic diseases; malignancies; psychiatric conditions; obesity; and idiopathic primary hyperhidrosis.
The absence of flushing or pallor and the extremely long duration of symptoms make a carcinoid or a pheochromocytoma less likely but do not exclude them. Although it is not unreasonable to get a 24-hour urine 5-HIAA and metanephrines later on in the endocrine workup, they are lower on the list (A). Endoscopic thoracic sympathectomy is a powerful tool to address idiopathic hyperhidrosis, but it may lead to compensatory sweating from other areas of the body and carries risks that could be avoided if one could treat the patient conservatively (B). Sweating is a frequent symptom of hypoglycemia, but this patient does not exhibit any other aspects of Whipple’s triad: symptoms of hypoglycemia, low blood sugar and resolving symptoms after carbohydrate intake (C). It is quite feasible to screen an obese patient with obstructive sleep apnea for hypogonadism, and both obesity and an imbalance between testosterone and estradiol have been reported in patients complaining of sweating (E).
However, before expensive investigations or surgery are initiated, it pays to ask about known or unknown triggers. In this case, I asked the patient to keep a diet log because he was also quite concerned about his BMI of 45. It turned out that he was consuming close to 1 g of caffeine daily in beverages such as coffee or cold green tea drinks. According to data from energyfiend.com, Starbucks 16-oz coffee has 330 mg (about twice what you’d find in McDonald’s coffee), a can of cola has about 40 mg to 70 mg and most bottles of iced tea have around 30 mg to 40 mg caffeine. My patient was particularly fond of an energy tea drink that contained 200 mg of caffeine per 16-oz bottle. I advised him to gradually wean off the caffeine. When he returned to my office three months later, he was intent on discussing his weight and borderline testosterone levels. I asked him about the sweating. “Oh, that? That’s gone. Completely. I have not had an episode since I stopped the coffee. Now, about that testosterone…”
Ronald Tamler, MD, PhD, MBA, is Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, N.Y.