Something to consider: Lyme disease and night sweats

Night sweats are excessive sweating that can affect the entire body without any environmental justification – for example, they do not stop even on cold nights. It affects 10-40% of adults. Although environmental factors (e.g. an overheated bedroom or thick blanket) are often responsible, in cases of pathological night sweats, internal medical, infectious or oncological causes must also be ruled out.

Hormonal changes: menopause, hyperthyroidism (overactive thyroid gland, which can be caused directly by an autoimmune reaction resulting from Lyme disease – see Hashimoto’s disease), hormone-producing tumours.

Infections: tuberculosis, HIV, tick-borne diseases such as Lyme disease or Babesiosis, endocarditis, osteomyelitis, and other chronic or subacute infections.

Tumours: especially lymphomas (which can also be secondary signs of Lyme disease), but also other haematological malignancies.

Medications: antidepressants, antipyretics, hormone replacement therapies.

Neurological and autoimmune diseases: for example, Parkinson’s disease, systemic lupus erythematosus.

Psychological conditions: anxiety, panic disorder.

It is extremely important to identify the cause of night sweats as soon as possible so that the patient can receive appropriate treatment.

Persistent, unexplained night sweats are often caused by an infectious disease. Two tick-borne pathogens that are becoming increasingly common deserve special attention. It is worth noting that almost all of the above possible causes can be a further symptom or complication of Lyme disease or babesiosis.

It is caused by the Borrelia burgdorferi bacterium and is mainly spread by Ixodes ticks. Early symptoms may include flu-like complaints, fatigue, muscle and joint pain, and night sweats. As the disease progresses, neurological or cardiological complications may also occur. As the symptoms are non-specific, diagnosis is often delayed. Complications can be prevented with early, targeted antibiotic treatment.

Numerous articles in the literature mention night sweats in connection with Lyme disease, but the symptom is not specific to the disease. It may occur with initial flu-like symptoms, but is most commonly reported by patients in connection with later complications of Lyme disease.

A 41-year-old previously healthy man was taken by ambulance to the emergency department following an episode of fainting. The ECG showed right bundle branch block with first-degree atrioventricular block. During his admission, he was found to have night sweats and elevated procalcitonin levels. Infectious disease testing yielded a positive Borrelia ELISA result. Further testing revealed positive Borrelia immunoglobulin M but negative immunoglobulin G, indicating a recent infection.

A 52-year-old woman presented with intermittent fever, dry cough, fatigue, diffuse headache, night sweats, unintentional weight loss, and neurological symptoms such as double vision (diplopia), tremor, sensory disturbance (paresthesia), and ataxia.

Serum and cerebrospinal fluid (CSF) testing revealed Borrelia burgdorferi-specific antibody index positivity and oligoclonal IgG bands in the CSF, suggesting intrathecal production of Borrelia-specific antibodies. The clinical and biochemical picture thus pointed to neurological complications of Lyme disease.

Surprisingly, MRI showed inflammation in the rhombencephalon, which is rare in patients with neuroborreliosis.

The patient was treated with intravenous ceftriaxone, which resulted in rapid improvement of symptoms. Six weeks after the start of antibiotic treatment, the MRI abnormalities had already regressed, and approximately seven months later, they had completely normalised.

A 63-year-old man presented with newly developed painful double vision lasting 1 day and was diagnosed with right sixth cranial nerve palsy. His medical history included recurrent polychondritis (an autoimmune disease of unknown origin), which had previously been associated with ophthalmic complications, so the paralysis was initially attributed to a flare-up of this systemic disease. However, as the patient also reported recent night sweats, an infectious cause was considered. Initially, oral steroid treatment was administered, but this did not improve his double vision, so he was admitted to hospital for further investigation. Approximately one week after admission, Lyme tests proved positive and the diagnosis was changed to abducens paralysis caused by Lyme disease. The patient’s symptoms improved rapidly with oral doxycycline treatment.

This is a disease caused by a protozoan that is also transmitted by Ixodes ticks. The most common species in the United States is Babesia microti, while Babesia divergens is more common in Europe, particularly in Great Britain and France.

Clinical symptoms vary, ranging from mild complaints to severe illness. The milder form is characterised by fever, chills and sweating. Associated symptoms may include general weakness, headache, muscle pain and loss of appetite. Fever is the most common physical finding, and splenomegaly (enlarged spleen) may also occur. As the parasites infect red blood cells, haemolytic anaemia, often mild but sometimes more severe, is a characteristic symptom. Thrombocytopenia and elevated liver enzymes are also common. Severe disease can lead to multiple organ failure, including acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC).

A 77-year-old man presented to the emergency department with recurrent fever, chills, and night sweats for five days. He reported general malaise and decreased appetite. He had no weight loss, headache, neck stiffness, cough, shortness of breath, abdominal complaints, joint pain, or rash.

He had returned three weeks earlier from his usual annual trip to the northeastern United States. While there, he had visited the beach and worked in his garden. He did not recall being bitten by any insects.

The patient’s body temperature was 39.4 °C. His blood pressure and pulse were normal. The physical examination revealed no other abnormalities. The complete blood count showed pancytopenia: haemoglobin 9.7 g/dL, white blood cell count 2400 cells/μl, platelet count 40,000 cells/μl. He was diagnosed with acute renal failure.

Alanine transaminase (97 U/L), aspartate aminotransferase (296 U/L) and total bilirubin (1.7 mg/dL) levels were elevated. Lactate dehydrogenase levels were also higher than normal, while haptoglobin levels were low. In addition, reticulocytosis was observed.

Parasite rings were visible in the red blood cells in the patient’s blood smear. The arrangement of parasites in groups of four (Maltese cross shape) is rare but pathognomonic for babesiosis.

The diagnosis was therefore babesiosis, which was successfully treated with a combination of azithromycin and atovaquone.

It is important to mention the significance of co-infections spread by ticks, such as Borrelia burgdorferi, Babesia microti and Anaplasma, which often cause overlapping systemic symptoms that can result in a more severe and prolonged clinical picture. During such co-infections, the body’s inflammatory response may be more pronounced, leading to night sweats, elevated temperature, recurrent fever and general malaise. Since night sweats are a non-specific symptom but common in tick-borne infections, it is particularly important to recognise co-infections, as they require different treatment and can lead to serious complications if left untreated.

Sources

https://pubmed.ncbi.nlm.nih.gov/37355424/

https://pubmed.ncbi.nlm.nih.gov/35330755/

https://pubmed.ncbi.nlm.nih.gov/35001068/

https://pubmed.ncbi.nlm.nih.gov/27765389/