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Q. What is the possible diagnosis of increased perspiration which gets worse with stress?

Answered by
Dr. Thakre Mahendra Shivram
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Apr 15, 2020

Hello doctor,

Patient V is a 35-year-old woman. Many years ago, she suffered from increased perspiration during night, from the child. When 7-year-old this was continuous making several changes of clothes a day necessary. The situation was worse during physical or emotional stress. In addition, she had polydipsia but urine volumes were normal. She was underweight even though she had polyphagia and was with tiredness and asthenia. The latter was increased in recent years. She tried many treatment types but none successful and improvement in her condition was not seen.

By the time the patient was 37 kg, 160 cm and was eating 3,000-3,500 calories per day. Her blood pressure was normal with 100 beats per minute. Her temperature was 36.8°C - 37.8°C but sometimes rose to as high as 38.4°C. No thyroid toxicity or thyroid gland enlargement was present. Normal blood tests, except for an elevated 24-hour urine creatinine but it was noted that her basal metabolic rate varied between 140 and 210 percent above normal.

Specimens of muscle tissue were taken under local anesthesia from the patient. The latter showed that respiration could proceed at a nearly maximal rate in the absence of ADP. When ADP was supplied in excess, phosphorylation to produce ATP proceeded as normal.

I have to diagnose this patient, but I am in a dilemma because I think that from the details I have for her as mentioned above, the biochemical pathway that is likely to be dysfunctional is glycolysis or glucose. I am more towards the thought that she has a dysfunctional glycolysis pathway. Am I right for this or not what do you think? Also, can you please suggest me what might be the underlying cause for the symptoms of hypermetabolism seen at her and what can be an evolutionary advantage for her?

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Hi,

Welcome to icliniq.com.

I have gone through your case details. I am with your thought process of diagnosis. Let us try symptom analysis and the clinical syndrome that patient v has.

The major symptom is hyperhidrosis that is increase sweating. This can be due to primary hyperhidrosis or secondary hyperhidrosis. This is less likely primary hyperhidrosis. Generalized sweating is mostly due to an underlying systemic illness or as a side effect of medication while focal sweating is generally due to a neurologic disorder or primary hyperhidrosis.

In this case, it is generalized sweating, we need to find out are there signs and symptoms of:

• Infection (acute or chronic).

• Neoplasia.

• Metabolic/endocrine disease (diabetes, thyroid, pheochromocytoma, carcinoid).

• High catecholamine state (respiratory failure, heart disease, pain, drug/ETOH withdrawal).

• Drug therapy (Propranolol, antidepressants, Pilocarpine, Physostigmine).

• Neurologic disease (dysautonomia, diencephalic epilepsy, hypothalamic lesion, structural brain abnormality).

In your case, it has a high metabolic rate with the childhood-onset disease process. So metabolic, endocrine, and high catabolic state is likely diagnosis.

In the metabolic, it is more mitochondrial metabolic disorder likely diagnosis.

The mitochondrial damage results in defects in the electron transport chain can affect any tissue. Tissues requiring the highest levels of energy production are the most severely affected.

Certain “red flags” which should immediately increase the suspicion of a mitochondrial disorder. These include short stature, neurosensory hearing loss, progressive external ophthalmoplegia, axonal neuropathy, diabetes mellitus, hypertrophic cardiomyopathy, and renal tubular acidosis.

Hope this insight will help you.


The Probable causes:

Primary hyperhidrosis. Secondary hyperhidrosis, Metabolic myopathy.
Mitochondrial disorder electron chain transfer.
Morvan syndrome (autoimmune).

Investigations to be done:

Serum lactate. Muscle biopsy for metabolic myopathy. Mitochondrial disorder. Genetic analysis.

Probable diagnosis:

Mitochondrial disorder.

Treatment plan:

As per diagnosis antioxidants, vitamin E, and Riboflavin.

Preventive measures:

Avoid excessive exercise to keep hydrated.


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