Narcolepsy type 1 symptoms8/13/2023 Second nocturnal polysomnography performed with bilevel positive airway pressure showed sleep of a very poor quality, SOREM, sleep fragmentation, and multiple RBD manifestations. After a year on this treatment, a polysomnography and Maintenance of Wakefulness Test (MWT) were performed because the patient asked for a renewal of his driving license. To control RBD, the patient took 0.25 mg of clonazepam before a night’s sleep with a subjective improvement of RBD symptoms. Bilevel positive airway pressure in the automatic mode (expiratory pressure 4–16 mbar, pressure support 4–6 mbar) controlled obstructive sleep apnea (residual apnea-hypopnea index 1.6, T90 12%) with mild improvement of EDS. Based on the patient’s complaints, we raised the dosage to 50 mg of clomipramine and achieved a complete and permanent cataplexy resolution. Cataplexy disappeared for a few months when taking 25 mg but reoccurred occasionally afterwards. The first treatment was clomipramine because cataplexy was the patient’s major problem. Standard CSF analysis results were within the normal range.ĭiagnoses of NT1 with comorbid RBD and obstructive sleep apnea were set according to The International Classification of Sleep Disorders, Third Edition (ICSD-3, 2014). The patient’s serum and CSF was negative for IgLON5-IgG using commercially available cell-based assay (Euroimmun, Germany). A brain MRI did not reveal any abnormalities. The level of hypocretin in cerebrospinal fluid (CSF) was immeasurably low. Surprisingly, he scored 7 points on the Epworth Sleepiness Scale (ESS). The patient fell asleep in all 5 tests with a mean sleep latency of 2.1 min. On the following day, Multiple Sleep Latency Test (MSLT) confirmed EDS. Obstructive apneas were found with an apnea-hypopnea index of 25.8 events/h with low saturation (basal saturation 92%, 62% of time below 90% saturation ). No sleep-onset REM (SOREM) during the night was seen (REM sleep latency was 117 min). The nocturnal polysomnography showed sleep fragmentation (a sleep effectivity of 73%) and rapid eye movement (REM) sleep without atonia with behavioral manifestations (somniloquy, gesticulations, upper limb complex movements) corresponding to REM sleep behavior disorder (RBD). Objective neurological examination did not reveal any important neurological, physical, nor cognitive findings.
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