Differential Diagnosis

The patient's symptoms of hyperhidrosis, heat intolerance, night sweats, and occasional fever, combined with laboratory findings and medical history, suggest a range of potential diagnoses. These can be categorized as follows:

• Single Most Likely Diagnosis

  • Hyperthyroidism: The symptoms of hyperhidrosis, heat intolerance, and night sweats are classic for hyperthyroidism. Although not all symptoms are present (e.g., weight loss, palpitations), the combination of these symptoms with elevated ALT (which can be seen in hyperthyroidism due to increased liver metabolism) makes this a strong consideration. The patient's other conditions, such as obesity and NAFLD, could also contribute to or be exacerbated by hyperthyroidism.

• Other Likely Diagnoses

  • Infection: Despite the normal CRP, an occult infection (e.g., endocarditis, osteomyelitis, or an abscess) could explain the fever and night sweats. The slightly elevated ESR and absolute monocyte count could support this, although these findings are nonspecific.
  • Lymphoma: Night sweats, fever, and weight loss (not explicitly mentioned but could be part of the presentation) are classic "B symptoms" associated with lymphoma. The elevated ESR and slightly low absolute monocyte count could also be seen in lymphoma.
  • Chronic Inflammatory Conditions: Conditions like rheumatoid arthritis or other autoimmune diseases could explain the elevated ESR and some of the symptoms, although the specific constellation of symptoms and lab findings might not perfectly align.

• Do Not Miss Diagnoses

  • Tuberculosis (TB): Although less common in some populations, TB can present with night sweats, fever, and weight loss. It's a diagnosis that could be deadly if missed due to its treatability with appropriate antibiotics.
  • Pheochromocytoma: This rare tumor of the adrenal gland can cause episodic hypertension, sweating, and heat intolerance. Given the patient's history of hypertension, this diagnosis is crucial not to miss, as it requires specific treatment.
  • Hematologic Malignancies: Besides lymphoma, other hematologic malignancies like leukemia could present with similar symptoms and lab abnormalities.

• Rare Diagnoses

  • Thyroid Storm: A life-threatening complication of untreated or undertreated hyperthyroidism, characterized by exaggerated symptoms of hyperthyroidism.
  • Mastocytosis: A condition involving the accumulation of mast cells in one or more organs, which can cause a variety of symptoms including flushing, sweating, and fever.
  • Carcinoid Syndrome: Although typically associated with flushing and diarrhea, some patients might present with sweating and other symptoms due to a neuroendocrine tumor secreting serotonin and other substances.

Each of these diagnoses requires careful consideration of the patient's full clinical picture, including history, physical examination, and additional diagnostic testing as needed.