Night sweats, fever and itching are very common and usually have a simple cause, such as the menopause, an infection, medicines, anxiety, acid reflux or an overactive thyroid [1, 2]. When these symptoms come together, that is heavy, recurring night sweats, unexplained fever above 38°C and unexplained weight loss, especially with a swollen lymph node, they can be a sign of lymphoma or leukaemia [3, 8]. Long-lasting itching without a skin rash, itching with yellowing of the skin and eyes, or repeated itching after a bath or shower should also be shown to a doctor [5, 6, 7].
Key points
- Night sweats are very common, and in most people there is no serious illness behind them; in family-practice patients, night sweats were not linked with a shorter life [2].
- Tuberculosis and lymphoma are diseases in which night sweats are prominent, but today they are an uncommon cause of night sweats [1].
- Doctors call unexplained fever, heavy night sweats and unexplained weight loss the "B symptoms" of lymphoma; together, these three are worth checking [3].
- Long-lasting itching without skin changes did not raise the overall risk of cancer, but it did raise the chance of blood cancers and bile duct cancer; even so, these cancers were rare in these people [5].
- Nosebleeds are very common [9]; but repeated nosebleeds with easy bruising, tiny red spots under the skin or tiredness need a full blood count (CBC) [8].
Night sweats and cancer: which cancers cause heavy sweating?
Night sweats means sweating during sleep, sometimes so much that your nightclothes or sheets are soaked and need changing [1]. Many people have this from time to time, and most of them have no serious illness [2]. Common causes [1, 2, 4]:
- the menopause and hot flushes
- infections, from short-lived ones to long-lasting infections such as tuberculosis and HIV
- medicines: fever-reducing medicines, some blood pressure medicines, antidepressants, steroids and opioid painkillers; and also alcohol
- anxiety
- acid reflux, pauses in breathing during sleep (sleep apnoea), an overactive thyroid and low blood sugar at night
- cancer treatments: hormone therapy for breast cancer (such as tamoxifen) and for prostate cancer, removal of the ovaries or testicles, chemotherapy and radiotherapy
The cancers most often linked with night sweats are lymphoma (Hodgkin and non-Hodgkin) and leukaemia [1, 3, 8]. In these diseases the sweating is usually heavy and recurring, and it may come with fever, weight loss, tiredness or a swollen lymph node [3, 8]. Read more: symptoms of lymphoma and symptoms of leukaemia.
What is a cancer fever like? When are fever and chills a concern?
Most fevers are caused by infections and settle within a few days. In lymphoma and leukaemia, fever is usually described like this [3, 8]:
- a temperature of 38°C or higher with no clear cause, such as a cold or a urine infection
- together with heavy night sweats, weight loss, tiredness or a swollen lymph node
- in leukaemia, together with one infection after another, easy bruising or bleeding
Have a fever checked if it keeps coming back for no reason or does not settle. When fever comes with night sweats, the doctor can usually find or rule out the serious causes with a history, an examination and a few targeted tests [1].
Fever during chemotherapy is different: if you are having chemotherapy, a temperature of 38°C or higher, or chills, can be a sign of a dangerous infection; contact your treatment team straight away [12]. Read: low blood counts and preventing infection.
Itchy skin and cancer: when is itching a concern?
In a large UK study of more than 8700 people with long-lasting itching and no skin disease, the overall risk of cancer over the next 5 years was no higher than in others; but blood cancers were seen about twice as often, and bile duct cancer more often too. Even so, these cancers remained rare: fewer than 2 in every 1000 people per year [5]. In another study, itching was most strongly linked with cancers of the liver, gallbladder and bile ducts, blood cancers and skin cancer [6]. These patterns are worth checking:
Itching with jaundice
Show itching together with yellowing of the skin and the whites of the eyes to a doctor promptly; itching is strongly linked with cancers of the liver and bile ducts [5, 6]. Read: symptoms of liver cancer, symptoms of pancreatic cancer and bile duct cancer.
Itching after a bath or shower
Itching, burning or tingling after contact with water, mostly on the trunk and the upper arms and legs, is a common symptom of polycythaemia vera, a slow-growing blood cancer in which the bone marrow makes too many red blood cells. In a study of more than 400 patients, 2 in every 3 had this itch, and in most of them it had started on average about 3 years before the diagnosis [7]. In Hodgkin lymphoma, too, itching sometimes gets worse after bathing or drinking alcohol [3].
Itching with other symptoms
Long-lasting itching together with night sweats, fever, weight loss or a swollen lymph node may be due to lymphoma [3, 6]. Read: swollen lymph nodes: when to worry
Red, eczema-like patches (skin lymphoma)
A type of lymphoma that starts in the skin (mycosis fungoides) first appears as thin red patches that look like eczema, and later they may become raised or hardened. In another type (Sézary syndrome), the skin all over the body becomes red, itchy and peeling. The diagnosis is made with a skin biopsy [10]. If a patch that looks like eczema does not get better with the usual treatments, ask a skin specialist whether a biopsy is needed.
Nosebleeds and cancer; bruising and tiny red spots on the skin
Nosebleeds are very common: at least 6 in every 10 people have one at some point in their life, most nosebleeds are short and limited, and only about 6 in every 100 people seek medical care for them [9]. Blood-thinning and antiplatelet medicines (such as aspirin) and bleeding disorders (in the person or their family) make nosebleeds more frequent or more severe [9].
Leukaemia can cause easy bruising, bleeding and tiny, flat red spots under the skin (petechiae), which are caused by bleeding under the skin; these may come with tiredness, fever or repeated infections [8]. If you have repeated or long-lasting nosebleeds, especially with unexplained bruising, petechiae or tiredness, see a doctor for a full blood count (CBC) [8]. Nosebleeds that keep coming back from the same nostril should be checked with a nasal endoscopy [9].
To stop a nosebleed, press firmly and continuously on the soft lower part of the nose for at least 5 minutes [9].
What tests will the doctor do?
- 1
History and examination
The doctor asks about the pattern of the sweating or fever, your medicines, the menopause, weight loss and itching, and examines your lymph nodes, liver, spleen and skin. Most serious causes can be ruled out with this history, an examination and a few targeted tests [1].
- 2
Blood tests
A full blood count (CBC), a thyroid test, erythrocyte sedimentation rate (ESR) and, if needed, an HIV test [1].
- 3
Tuberculosis test and chest X-ray
A tuberculosis skin test and a plain chest X-ray [1].
- 4
When should I contact a doctor?
In these cases do not wait; see a doctor within the next few days:
- heavy, recurring night sweats together with fever, unexplained weight loss or a swollen lymph node [3]
- a temperature of 38°C or higher with no clear cause that keeps coming back or does not settle [3]
- long-lasting itching without a skin rash, or itching with yellowing of the skin and eyes [5, 6]
- repeated itching after contact with water [7]
- red, eczema-like patches that do not heal [10]
- unexplained bruising, tiny red spots under the skin or repeated nosebleeds [8, 9]
If you are having chemotherapy and have a temperature of 38°C or higher or chills, contact your treatment team straight away [12].
A nosebleed that does not stop with pressure, heavy bleeding, or a high fever with confusion or shortness of breath need urgent care; call your local emergency number.
Frequently asked questions
What are cancer night sweats like?
In lymphoma and leukaemia, the sweating is usually heavy, soaks clothes and sheets, comes back night after night, and may come with fever, weight loss or a swollen lymph node [1, 3]. Night sweats on their own, without these symptoms, are very common and are not usually a sign of serious illness [2].
Night sweats in middle-aged women: is it the menopause or cancer?
Is itchy skin a sign of leukaemia or other blood cancers?
Usually not. Long-lasting itching without skin disease roughly doubled the chance of blood cancers, but these cancers were still rare [5]. Always have itching checked if it comes with night sweats, fever, weight loss or a swollen lymph node [3]. Read: symptoms of lymphoma.
Does lymphoma cause a rash?
What does a leukaemia rash look like?
Mostly easy bruising and tiny, flat red spots under the skin (petechiae), which come from bleeding under the skin [8]. If you notice these spots without an injury, especially with tiredness or fever, see a doctor. Read: symptoms of leukaemia.
Is skin cancer itchy?
Sometimes. In a study of more than 300 skin cancers, about 1 in 3 was itchy, but melanoma was mostly neither itchy nor painful [11]. So a mole or skin sore that does not itch is not necessarily harmless. Read: symptoms of skin cancer.
Night sweats, fever and itching: definitions and evidence (for doctors)
For physicians
B symptoms. Unexplained weight loss of more than 10% of body weight in the 6 months before diagnosis, unexplained fever above 38°C, and drenching, recurrent night sweats; the most significant B symptoms for prognosis are fever and weight loss, and night sweats alone do not confer an adverse prognosis. Pruritus, especially after bathing or alcohol, is a presenting feature of Hodgkin lymphoma [3].
Night sweats. The classic definition is "drenching sweats that require a change of bedclothes", although most patients do not meet it. Tuberculosis and lymphoma are uncommon causes in current practice; other diagnoses include HIV, gastro-oesophageal reflux, obstructive sleep apnoea, hyperthyroidism, hypoglycaemia, and medicines (antihypertensives, antipyretics, antidepressants) and alcohol. If history and examination are unrevealing: PPD, CBC, HIV, TSH, ESR, chest radiograph and, if needed, CT of the chest and abdomen and a bone marrow biopsy [1]. In a systematic review, prevalence ranged from 10% among older primary care patients to 60% among women on an obstetric inpatient unit; the life expectancy of primary care patients with night sweats did not appear to be reduced, most suggested causes are poorly supported, and algorithmic evaluations are not evidence-based [2]. In patients with cancer, treatment-related causes include oophorectomy, chemotherapy, tamoxifen and aromatase inhibitors, orchiectomy and GnRH analogues, radiotherapy, and medicines such as opioids, tricyclic antidepressants and steroids [4].
Pruritus. In the population-based THIN cohort (8744 patients with chronic pruritus without skin disease versus 31,580 controls), the adjusted HR for any malignancy was 1.14 (0.98 to 1.33), for haematological malignancy 2.02 (1.48 to 2.75) and for bile duct malignancy 3.73 (1.55 to 8.97); the incidence of haematological malignancy was 0.0016 and of cholangiocarcinoma 0.0003 per person-year [5]. In a cross-sectional study of 16,925 patients with pruritus at Johns Hopkins, the OR for concomitant malignancy was 5.76 (5.53 to 6.00), with the strongest associations for cancers of the liver, gallbladder and biliary tract, the haematopoietic system and the skin [6]. Aquagenic pruritus in polycythaemia vera: 301 of 441 patients; in 64.8% it began on average 2.9 years before diagnosis, and only 15.4% had it lead to a haematological work-up; 14.6% described it as "unbearable" [7]. In 339 excised skin cancers (166 BCC, 146 SCC and 27 melanomas), the prevalence of itch was 36.9% and of pain 28.2%, and these symptoms were mostly absent in melanoma [11].
Epistaxis. At least 60% of people have a nosebleed at some point, and about 6% seek medical care. AAO-HNSF guideline 2020: document factors that increase bleeding (personal or family history of bleeding disorders, anticoagulant or antiplatelet medicines, intranasal drug use), apply firm sustained compression to the lower third of the nose for at least 5 minutes, and perform nasal endoscopy for recurrent bleeding despite treatment or for recurrent unilateral bleeding [9]. During cancer treatment, a temperature of 38°C or higher and chills are signs of infection that require contacting the treatment team, and infection in this period can be life-threatening [12]; for assessment and treatment see the lesson febrile neutropenia.
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References
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