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NARCOLEPSY type 1 AND REM SLEEP WITHOUT ATONIA (RSWA): WHAT IS THE RELATIONSHIP TO REM SLEEP BEHAVIOR DISORDER (RBD) AND OBSTRUCTIVE SLEEP APNEA ?: CASE REPORT
Narcolepsy type 1 is a sleep disorder characterized by excessive daytime sleepiness, cataplexy, sleep paralysis and it is usually associated with other sleep conditions. We report a case of a patient with narcolepsy type 1, who presented with REM Sleep Behavior Disorder (RBD) features and obstructive sleep apnea (OSA) in sleep studies.
The purpose of this case report is to highlight the importance of evaluating other sleep conditions associated with Narcolepsy.
A 34-year-old man with a history of excessive daytime sleepiness since he was 15 years old, associated to loss of muscle tone often triggered by pleasant emotions. He had been hospitalized at age 17 for hypnagogic and hypnopompic hallucinations, being medicated with benzodiazepines, antidepressants and antipsychotics, leading to deterioration of its clinical condition, over the years. The consequences were weight gain, learning disability and irritability; frequente he was fired from his jobs. At 32 years old, he was diagnosed with Narcolepsy, and treatment with Modafinil and Nortriptyline lead to partial symptom improvement.
Due to residual symptoms of excessive daytime sleepiness, cataplexy and hypnagogic and hypnopompic hallucinations, as well as his wife's report of abnormal behaviors during sleep and a 10 kg weight gain in the last year, with increased snoring intensity, polysomnography, actigraphy and multiple sleep latency test were requested.
Polysomnography showed severe obstructive sleep apnea, and motor behaviors compatible with diagnosis of RDB. The multiple sleep latency test revealed a mean sleep latency of less than 8 min with 5 episodes of REM sleep, confirming diagnostic of Narcolepsy. Actigraphy pattern indicated sleep fragmentation.
In narcolepsy, RBD and RSWA are associated conditions, probably related to the role of hypocretin in REM tone loss. In narcoleptic patients, the RDB age onset is earlier than usual, the movements during the episode are less complex and less violent.
Isolated obstructive sleep apnea may cause abnormal behaviors during sleep, but it is usually less severe, due to maintainance of tone in this situations.
Given Narcolepsy with difficulty in controlling symptoms, it is important to investigate other sleep disorders, like RDB and OSA. Asking about dream enactement or symptons of sleep apnea, may help to better define the differential diagnosis.
narcolepsy, apnea, REM sleep behavior disorder
Relato de Caso
IPq- HC-FMUSP - Sao Paulo - Brasil
Viviane Vieira Passini, Cassio Batista Lacerda, Mariana Delgado Fernandes, Andrea Cecilia Toscanini, Daniel Guilherme Suzuki Borges, Alexandre Pinto de Azevedo, Rosa Hasan