1
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Marčić M, Marčić L, Marčić B. SARS-CoV-2 Infection Causes Relapse of Kleine-Levin Syndrome: Case Report and Review of Literature. Neurol Int 2021; 13:328-334. [PMID: 34294673 PMCID: PMC8299328 DOI: 10.3390/neurolint13030033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022] Open
Abstract
Recurrent episodes of hypersomnia, hypersexuality, compulsive eating, behavioral and cognitive disturbances, are the basic clinical features of Kleine-Levin syndrome (KLS). Our case report describes a patient who was diagnosed with KLS at the age of 20. With appropriate therapy, the disease had a satisfactory course until patient had a moderate form of SARS-CoV-2 infection, which led to a significant exacerbation of all symptoms. SARS-CoV-2 virus can cause almost any neurological disease, and relapse of KLS is another evidence of neurotropicity of the virus.
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Affiliation(s)
- Marino Marčić
- Department of Neurology, University Hospital Center Split, Spinčićeva1, 21000 Split, Croatia
- Correspondence:
| | - Ljiljana Marčić
- Department of Radiology, Polyclinic Medikol, 21000 Split, Croatia;
| | - Barbara Marčić
- Department of Histology, School of Medicine, University of Mostar, 88000 Mostar, Bosnia and Herzegovina;
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2
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Pisano S, Pozzi M, Catone G, Scrinzi G, Clementi E, Coppola G, Milone A, Bravaccio C, Santosh P, Masi G. Putative Mechanisms of Action and Clinical Use of Lithium in Children and Adolescents: A Critical Review. Curr Neuropharmacol 2019; 17:318-341. [PMID: 29256353 PMCID: PMC6482478 DOI: 10.2174/1570159x16666171219142120] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/09/2017] [Accepted: 11/28/2017] [Indexed: 01/17/2023] Open
Abstract
Background: Lithium is a first-line treatment for bipolar disorder in adults, but its mechanism of action is still far from clear. Furthermore, evidences of its use in pediatric populations are sparse, not only for bipolar disorders, but also for other possible indications. Objectives: To provide a synthesis of published data on the possible mechanisms of action of lithium, as well as on its use in pediatric samples, including pharmacokinetics, efficacy, and safety data. Methods: Clinical trials in pediatric samples with at least one standardized measure of efficacy/effectiveness were included in this review. We considered: i) randomized and open label trials, ii) combination studies iii) augmentation studies iv) case series including at least 5 patients. Results: Different and non-alternative mechanisms of action can explain the clinical efficacy of lithium. Clinical studies in pediatric samples suggest that lithium is effective in managing manic symptoms/episodes of bipolar disorder, both in the acute phase and as maintenance strategy. Efficacy on depressive symptoms/phases of bipolar disorder is much less clear, while studies do not support its use in unipolar depression and severe mood dysregulation. Conversely, it may be effective on aggression in the context of conduct disorder. Other possible indications, with limited published evidence, are the acute attacks in Kleine-Levin syndrome, behavioral symptoms of X-fragile syndrome, and the management of clozapine- or chemotherapy- induced neutropenia. Generally, lithium resulted relatively safe. Conclusions: Lithium seems an effective and well-tolerated medication in pediatric bipolar disorder and aggression, while further evidences are needed for other clinical indications.
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Affiliation(s)
- Simone Pisano
- Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Gennaro Catone
- Dept. of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Campania University- Luigi Vanvitelli, Italy
| | - Giulia Scrinzi
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Child Neuropsychiatry Unit, University of Verona, Verona 37126, Italy
| | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.,Unit of Clinical Pharmacology, CNR Institute of Neuroscience, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, 20157 Milan, Italy
| | - Giangennaro Coppola
- Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Annarita Milone
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Carmela Bravaccio
- Department of Translational Medical Sciences, University Federico II of Naples, Italy
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.,Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), National and Specialist Child and Adolescent Mental Health Services, Maudsley Hospital, London, United States.,HealthTracker Ltd, Gillingham, United States
| | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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3
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Al Shareef SM, Almeneessier AS, Smith RM, BaHammam AS. The clinical characteristics of Kleine–Levin syndrome according to ethnicity and geographic location. Int J Neurosci 2018; 128:842-848. [DOI: 10.1080/00207454.2018.1437037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Saad M. Al Shareef
- Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | | | - Richard M. Smith
- Department of Medicine, Ipswich Hospital NHS Trust, University of Suffolk, Ipswich, UK
| | - Ahmed S. BaHammam
- University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia, Saudi Arabia
- Strategic Technologies Program, National Plan for Sciences and Technology and Innovation, Riyadh, Saudi Arabia
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4
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AlShareef SM, Smith RM, BaHammam AS. Kleine-Levin syndrome: clues to aetiology. Sleep Breath 2018; 22:613-623. [PMID: 29532411 PMCID: PMC6133116 DOI: 10.1007/s11325-017-1617-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/19/2017] [Accepted: 12/29/2017] [Indexed: 12/22/2022]
Abstract
Kleine-Levin syndrome (KLS) is the commonest recurrent sleep disorder, with a prevalence of 1-2 per million population. Clear diagnostic criteria are now defined, but effective treatment remains elusive. The significant body of published literature allows consideration of possible aetiological mechanisms, an understanding of which could guide the development of therapeutic strategies. Functional imaging studies have been inconclusive; although diencephalic abnormalities are a common finding, no consistent pattern has emerged, and these studies have not revealed the mechanism(s) underlying the development of the abnormalities detected. An autoimmune aetiology is consistent with the available data. In this review, we argue that, in order to further our understanding of KLS, there needs to be a co-ordinated international effort to standardise approaches to functional imaging studies, genetic analyses that specifically address the possibility of an autoimmune aetiology, and clinical trials of immunosuppressive therapies.
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Affiliation(s)
- Saad Mohammed AlShareef
- Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Richard Mark Smith
- Division of Medicine and Therapeutics, Ipswich Hospital NHS Trust and University of Suffolk, Heath Road, Ipswich, Suffolk, IP4 5PD UK
| | - Ahmed Salem BaHammam
- The University Sleep Disorders Center and National Plan for Science and Technology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Al Shareef SM, Basit S, Li S, Pfister C, Pradervand S, Lecendreux M, Mayer G, Dauvilliers Y, Salpietro V, Houlden H, BaHammam AS, Tafti M. Kleine-Levin syndrome is associated with LMOD3 variants. J Sleep Res 2018; 28:e12718. [PMID: 29923248 DOI: 10.1111/jsr.12718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/16/2018] [Accepted: 05/16/2018] [Indexed: 11/30/2022]
Abstract
Kleine-Levin syndrome (KLS) is a rare periodic hypersomnia with associated behavioural abnormalities but with often favourable prognosis. There is excess risk of KLS in first-degree relatives, suggesting a strong genetic contribution. So far, no mutation is identified in KLS and comprehensive genetic analysis of affected individuals is lacking. Here we performed whole genome single-nucleotide polymorphism (SNP) genotyping and exome sequencing in a large family with seven affected members. The identified gene with a mutation was resequenced in 38 sporadic KLS patients and the expression of the gene product was mapped in the mouse brain. Linkage analysis mapped the disease locus to chromosome 3 and exome analysis identified a heterozygous missense variant in LMOD3 (p.E142D) in the linkage interval. The variant was found to segregate in all affected and one presumably unaffected member of the family. Resequencing LMOD3 in 38 other KLS patients and their families revealed three other low frequency or rare missense variants in seven cases that were inherited with incomplete penetrance. LMOD3 is expressed in the brain and colocalized with major structures involved in the regulation of vigilance states. LMOD proteins are structural proteins and seem to be developmentally regulated. Our findings suggest that KLS might be a structural/neurodevelopmental brain disease.
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Affiliation(s)
- Saad M Al Shareef
- Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Sulman Basit
- College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
| | - Sha Li
- Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Corinne Pfister
- Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Sylvain Pradervand
- Genomic Technologies Facility, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Michel Lecendreux
- AP-HP, Pediatric Sleep Center and National Reference Center for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Robert-Debré Hospital, Paris, France
| | - Geert Mayer
- Hephata Klinik, Scwalmstadt, and Philipps University of Marburg, Marburg, Germany
| | - Yves Dauvilliers
- Reference National Center for Narcolepsy, Department of Neurology, Gui-de-Chauliac Hospital, INSER U106, Montpellier, France
| | - Vincenzo Salpietro
- Department of Molecular Neuroscience, Institute of Neurology, University College of London, London, UK
| | - Henry Houlden
- Department of Molecular Neuroscience, Institute of Neurology, University College of London, London, UK
| | - Ahmed S BaHammam
- College of Medicine, University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia.,The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation, Riyadh, Saudi Arabia
| | - Mehdi Tafti
- Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland.,Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), Lausanne, Switzerland
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6
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Abstract
Kleine-Levin syndrome (KLS) is a rare disorder characterized by discrete episodes of hypersomnia associated with cognitive and behavioural abnormalities, as well as normal alertness and function between episodes. The prevalence of KLS may be underestimated as it is often misdiagnosed and managed as another sleep disorder, neurological disorder or psychiatric condition. KLS is more typically seen in adolescence than at other ages, and is more common in males than in females. There are currently neither standard biomarkers nor specific imaging study findings, making the diagnosis of KLS a challenge. Furthermore, there are no consistently effective therapies. The prognosis, however, is felt to be overall favorable, as episodes become progressively milder and less frequent before resolving entirely in most patients.
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Affiliation(s)
- Olufunke Afolabi-Brown
- Sleep Center, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104.
| | - Thornton B A Mason
- Sleep Center, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104.
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Al Suwayri SM, BaHammam AS. The "Known Unknowns" of Kleine-Levin Syndrome: A Review and Future Prospects. Sleep Med Clin 2017; 12:345-358. [PMID: 28778233 DOI: 10.1016/j.jsmc.2017.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Kleine-Levin syndrome (KLS) is a rare, homogeneous, debilitating sleep disorder characterized by episodic hypersomnia, cognitive impairment, and behavioral changes. The etiology, pathophysiology, and optimal management of KLS remain uncertain. We identify the 5 key areas requiring urgent attention: KLS immunopathogenesis studies, next-generation genetics, multimodal functional imaging, biomarker discovery, and clinical drug trials. A centralized registry of afflicted individuals must be established. Disease uniformity should make the identification of associated genetic or imaging biomarkers easier, but clinical efforts require laboratory-based research to model the disease and generate preclinical data for clinical translation.
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Affiliation(s)
- Saad M Al Suwayri
- Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), PO Box 7544, Othman bin Afan Road, Riyadh, Saudi Arabia
| | - Ahmed S BaHammam
- University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Box 225503, Riyadh 11324, Saudi Arabia.
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8
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Nguyen QTR, Groos E, Leclair-Visonneau L, Monaca-Charley C, Rico T, Farber N, Mignot E, Arnulf I. Familial Kleine-Levin Syndrome: A Specific Entity? Sleep 2016; 39:1535-42. [PMID: 27253765 DOI: 10.5665/sleep.6014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 04/25/2016] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Kleine-Levin syndrome (KLS) is a rare, mostly sporadic disorder, characterized by intermittent episodes of hypersomnia plus cognitive and behavior disorders. Although its cause is unknown, multiplex families have been described. We contrasted the clinical and biological features of familial versus sporadic KLS. METHODS Two samples of patients with KLS from the United States and France (n = 260) were studied using clinical interviews and human leukocyte antigen (HLA) genotyping. A multiplex family contained two or more first- or second-degree affected relatives (familial cases). RESULTS Twenty-one patients from 10 multiplex families (siblings: n = 12, including two pairs of monozygotic twins; parent-child: n = 4; cousins: n = 2; uncle-nephews: n = 3) and 239 patients with sporadic KLS were identified, yielding to 4% multiplex families and 8% familial cases. The simplex and multiplex families did not differ for autoimmune, neurological, and psychiatric disorders. Age, sex ratio, ethnicity, HLA typing, karyotyping, disease course, frequency, and duration of KLS episodes did not differ between groups. Episodes were less frequent in familial versus sporadic KLS (2.3 ± 1.8/y versus 3.8 ± 3.7/y, P = 0.004). Menses triggered more frequently KLS onset in the nine girls with familial KLS (relative risk, RR = 4.12, P = 0.03), but not subsequent episodes. Familial cases had less disinhibited speech (RR = 3.44, P = 0.049), less combined hypophagia/hyperphagia (RR = 4.38, P = 0.006), more abrupt termination of episodes (RR = 1.45, P = 0.04) and less postepisode insomnia (RR = 2.16, P = 0.008). There was similar HLA DQB1 distribution in familial versus sporadic cases and no abnormal karyotypes. CONCLUSION Familial KLS is mostly present in the same generation, and is clinically similar to but slightly less severe than sporadic KLS.
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Affiliation(s)
- Quang Tuan Remy Nguyen
- National Reference Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Sleep Disorders Unit and Hospital-University Institute of Neuroscience, Pitié-Salpêtrière Hospital (APHP), Pierre and Marie Curie University, Paris, France
| | - Elisabeth Groos
- National Reference Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Sleep Disorders Unit and Hospital-University Institute of Neuroscience, Pitié-Salpêtrière Hospital (APHP), Pierre and Marie Curie University, Paris, France
| | - Laurène Leclair-Visonneau
- Regional Competence Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Laennec University Hospital, Nantes, France
| | - Christelle Monaca-Charley
- Regional Competence Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Salengro University Hospital, Lille, France
| | - Tom Rico
- Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA
| | - Neal Farber
- Kleine-Levin Syndrome Foundation, Boston, MA
| | - Emmanuel Mignot
- Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA
| | - Isabelle Arnulf
- National Reference Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Sleep Disorders Unit and Hospital-University Institute of Neuroscience, Pitié-Salpêtrière Hospital (APHP), Pierre and Marie Curie University, Paris, France
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9
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Abstract
BACKGROUND This is an updated version of the original Cochrane review, published in 2009, Issue 2.Kleine-Levin syndrome (KLS) is a rare disorder that mainly affects adolescent men. It is characterised by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behaviour, such as hypersexuality, and signs of dysautonomia.In 1990, the diagnostic criteria for Kleine-Levin syndrome were modified in the International Classification of Sleep Disorders, where KLS was defined as a syndrome comprised of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behaviour. According to the International Classification of Sleepiness Disorders, 3rd version (ICSD-3), revised in 2014, the Kleine-Levin syndrome is a disorder characterized by recurrent episodes of hypersomnia that last from two days to four weeks, with at least annual recurrence, and hyperphagia (rapid consumption of a large amount of food), usually with onset in early adolescence in males but occasionally in later life and in women. A monosymptomatic form of the disorder with hypersomnia only can occur without binge eating or hypersexuality.The cause of Kleine-Levin syndrome remains unknown, and several treatment strategies have been used. Some medications have been reported to provide benefit in the treatment of patients with KLS, but because of the rarity of the condition, no long-term follow-up therapies have yet been described. OBJECTIVES This review aimed to evaluate:1. whether pharmacological treatment for Kleine Levin syndrome was effective and safe.2. which drug or category of drugs was effective and safe. SEARCH METHODS For the latest update, we searched the following sources: the Cochrane Epilepsy Group Specialized Register (7 April 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online CRSO (7 April 2016); MEDLINE (1946 to April 2016); LILACS (7 April 2016); ClinicalTrials.gov (7 April 2016); WHO International Clinical Trials Registry Platform ICTRP (7 April 2016); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-randomised controlled trials looking at pharmacological interventions for Kleine-Levin syndrome were eligible. We had planned to include both parallel-group and cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors (MMO and CC) had planned to extract the data reported in the original articles. MAIN RESULTS No studies met the inclusion criteria for this systematic review. AUTHORS' CONCLUSIONS Therapeutic trials of pharmacological treatment for Kleine-Levin syndrome with a double-blind, placebo-controlled design are needed.
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Affiliation(s)
- Marcio M de Oliveira
- Universidade Federal de São PauloRua Pedro de Toledo, 598São PauloSão PauloBrazil04039‐001
| | - Cristiane Conti
- Universidade Federal de São PauloRua Pedro de Toledo, 598São PauloSão PauloBrazil04039‐001
| | - Gilmar F Prado
- Escola Paulista de Medicina, Universidade Federal de São PauloDepartment of NeurologySão PauloSão PauloBrazil
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10
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Abstract
Objectives: To highlight the occurrence of familial cases and addresses, whether familial Kleine-Levine syndrome (KLS) presents the same spectrum of disease, as that seen in sporadic KLS. Methods: Between September and December 2014, reports of familial cases of KLS were identified by searching the Library of Congress, PubMed, and Web of Science databases restricted to the English language, with no restriction on date of publication. All cases were reviewed to identify familial cases consistent with current diagnostic criteria for sporadic KLS. Results: Six reviews and 11 case reports describing cases of familial KLS were identified. In 17 of the 29 familial cases identified, sufficient clinical details were described to be confident that these cases were familial and consistent with the description of KLS in the International Classification of Sleep Disorders 3rd edition (ICSD-3), and recent detailed reviews of sporadic KLS. Conclusion: A significant number of familial cases of KLS have been described that are consistent with the ICSD-3 description of KLS, and indistinguishable from sporadic KLS. This suggests that study of familial KLS using modern genetic techniques may be useful in elucidating the pathogenesis of this rare condition.
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Affiliation(s)
- Saad M Al Suwayri
- Department of Internal Medicine, College of Medicine, Al-Imam Muhammed Ibn Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail.
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11
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Jain RS, Kumar S, Srivastava T, Sannegowda RB. Kleine-Levin syndrome with comorbid iron deficiency anemia. Oxf Med Case Reports 2015; 2015:226-8. [PMID: 26634130 PMCID: PMC4664840 DOI: 10.1093/omcr/omv019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 02/12/2015] [Accepted: 02/16/2015] [Indexed: 11/13/2022] Open
Abstract
Kleine–Levin syndrome (KLS) is a rare chronic sleep disorder of unknown etiopathology, which typically occurs in adolescent males. Although the severity of symptoms and disease course varies between the KLS patients, it usually resolves spontaneously, but sometime comorbid conditions may worsen the symptoms. Herein, we report a case of KLS who presented with severe episodic hypersomnia. During episodes, the patient used to sleep as long as 20 h in a day, affecting his daily living activities. All the relevant investigations including electroencephalography, magnetic resonance imaging of brain and cerebrospinal fluid analysis were normal except for severe iron deficiency anemia (IDA). In our patient, the severity of symptoms worsened due to coexistent IDA. The treatment of IDA along with modafinil decreased the severity of symptoms and shortened the hospital stay during episodes. This might be the first case report of KLS with comorbid IDA.
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Affiliation(s)
| | - Sunil Kumar
- Correspondence address. Department of Neurology, Sawai Man Singh Medical College, Jaipur, Rajasthan 302004, India. E-mail:
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12
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Abstract
Excessive daytime sleepiness has significant impact on neurological function, and has societal implications. Sleepiness is a common feature of many neurological conditions. A careful history will often reveal one of many common causes of excessive daytime sleepiness and suggest appropriate treatment. Neurophysiological testing can provide objective assessment. Behavioural management is an important first step in management. Treatment of common concurrent sleep disorders is also essential. Currently available medications can further symptomatically improve function in many individuals. The strongest evidence base is for the treatment of narcolepsy - a prototype disorder of excessive daytime sleepiness. Currently used medications include modafinil, stimulants, and sodium oxybate amongst others. This review discusses important features in the diagnosis of daytime sleepiness in adults, and outlines a treatment approach. Further evidence-based information about the management of this common problem is essential.
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13
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[The Kleine-Levin syndrome: new aspects of a rare disease]. DER NERVENARZT 2013; 84:1207-12. [PMID: 23942582 DOI: 10.1007/s00115-013-3858-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The Kleine-Levin syndrome (KLS) is a rare disease which can occur one to several times per year. The KLS belongs to the group of hypersomnia of central origin occurring mainly during the second decade of life after infections, sleep deprivation, alcohol consumption or minor trauma. Early manifestation combined with hypersexuality during symptomatic phases can be a predictor for a long course of the disease, which lasts a mean of 1-27 years. Due to the lack of biological markers diagnosis at first manifestation is difficult. The classical trias of hypersomnia, hyperphagia and hypersexuality can only be found in 45 % of patients. The dominant clinical symptoms are hypersomnia with changes in perception and behavior. Subtraction of perfusion studies performed during symptomatic and asymptomatic phases showed decreased perfusion of the left hypothalamus, thalamus, basal ganglia, medial and dorsolateral frontal and temporal regions. In the few patients who had lumbar punctures in both symptomatic and asymptomatic phases hypocretin-1 was moderately to slightly lowered during symptomatic phases. Meta-analyses showed good therapeutic effects of stimulants on the symptom sleepiness. Lithium reduces the frequency and duration of symptomatic phases. Assuming that KLS is underdiagnosed it should be considered as a differential diagnosis in young patients with recurrent hypersomnia.
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14
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Abstract
BACKGROUND This is an updated version of the original Cochrane review, published in Issue 2, 2009.Kleine-Levin syndrome (KLS) is a rare disorder that mainly affects adolescent men. It is characterised by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behavior such as hypersexuality and signs of dysautonomia.In 1990 the diagnostic criteria for Kleine-Levin syndrome were modified in the International Classification of Sleep Disorders, where KLS was defined as a syndrome composed of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behavior.The cause of Kleine-Levin syndrome remains unknown, and several treatment strategies have been used. Some medications have been reported to provide benefit in the treatment of patients with KLS, but because of the rarity of the condition, no long-term follow-up therapies have yet been described. OBJECTIVES This review aimed to evaluate:1. whether pharmacological treatment for Kleine Levin syndrome is effective and safe.2. which drug or category of drugs is effective and safe. SEARCH METHODS We obtained relevant trials from the following sources: the Cochrane Epilepsy Group Specialized Register (2 May 2013); the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, The Cochrane Library, April 2013); MEDLINE (1946 to 2 May 2013); SCOPUS (2 May 2013); LILACS (2 May 2013); ClinicalTrials.gov (2 May 2013); WHO International Clinical Trials Registry Platform ICTRP (2 May 2013); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-randomised controlled trials looking at pharmacological interventions for Kleine-Levin syndrome were selected. We included both parallel-group and cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors (MMO and CC) extracted the data reported in the original articles. MAIN RESULTS No studies met the inclusion criteria for this systematic review. AUTHORS' CONCLUSIONS Therapeutic trials of pharmacological treatment for Kleine-Levin syndrome with a double-blind, placebo-controlled design are needed.
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Affiliation(s)
- Marcio M Oliveira
- Universidade Federal de São Paulo, Rua Pedro de Toledo, 598, São Paulo, São Paulo, Brazil, 04039001
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16
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Abstract
OPINION STATEMENT Dyssomnias are sleep disorders associated with complaints of insomnia or hypersomnia. The daytime sleepiness of narcolepsy is treated by a combination of planned daytime naps, regular exercise medications such as modafinil, or salts of methylphenidate, or amphetamine. Cataplexy that accompanies narcolepsy is treated with anticholinergic agents, selective serotonin reuptake inhibitors, or sodium oxybate. Children with neurodevelopmental disabilities such as autism have sleep initiation and maintenance difficulties on a multifactorial basis, with favorable response to melatonin in some patients. Childhood onset restless legs syndrome is often familial, associated with systemic iron deficiency, and responsive to iron supplementation and gabapentin. Parasomnias are episodic phenomena events which occur at the sleep -- wake transition or by intrusion on to sleep. Arousal parasomnias such as confusional arousals and sleep walking can sometimes be confused with seizures. A scheme for differentiating arousal parasomnias from nocturnal seizures is provided. Since arousal parasomnias are often triggered by sleep apnea, restless legs syndrome, or acid reflux, treatment measures directed specifically at these disorders often helps in resolution. Clonazepam provided in a low dose at bedtime can also alleviate sleep walking and confusional arousals. Obstructive sleep apnea affects about 2 percent of children. Adeno-tonsillar hypertrophy, cranio-facial anomalies, and obesity are common predisposing factors. Mild obstructive sleep apnea can be treated using a combination of nasal corticosteroids and a leukotriene antagonist. Moderate to severe obstructive sleep apnea are treated with adeno-tonsillectomy, positive airway pressure breathing devices, or weight reduction as indicated. This paper provides an overview of the topic, with an emphasis on management steps. Where possible, the level of evidence for treatment recommendations is indicated.
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Affiliation(s)
- Suresh Kotagal
- Neurology, Pediatrics and the Center for Sleep Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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Abstract
Central hypersomnias are diseases manifested in excessive daytime sleepiness (EDS) not caused by disturbed nocturnal sleep or misaligned circadian rhythms. Central hypersomnias includes narcolepsy with and without cataplexy, recurrent hypersomnia, idiopathic hypersomnia, with and without long sleep time, behaviorally induced insufficient sleep syndrome, hypersomnia and narcolepsy due to medical conditions, and finally hypersomnia induced by substance intake. The Epworth Sleepiness Scale is a subjective tool mostly used for EDS assessment, while the Multiple Sleep Latency Test serves as an objective diagnostic method for narcolepsy and idiopathic hypersomnias. As for symptomatic therapy of EDS, the central nervous system stimulants modafinil and methylphenidate seem to work well in most cases and in narcolepsy and Parkinson's disease; sodium oxybate also has notable therapeutic value.
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Affiliation(s)
- Karel Sonka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Katerinska 30, Prague, Czech Republic
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Comorbidities of Central Nervous System Hypersomnia. Sleep Med Clin 2012. [DOI: 10.1016/j.jsmc.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Ueno T, Fukuhara A, Ikegami A, Ohishi F, Kume K. Monozygotic twins concordant for Kleine-Levin syndrome. BMC Neurol 2012; 12:31. [PMID: 22646233 PMCID: PMC3502424 DOI: 10.1186/1471-2377-12-31] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 05/30/2012] [Indexed: 11/16/2022] Open
Abstract
Background Kleine-Levin syndrome is a rare sleep disorder of unknown etiology. It is characterized by intermittent periods of excessive sleepiness, cognitive disturbances and behavioral abnormalities. Nine cases of familial Kleine-Levin syndrome have been identified, but there are no reported cases describing twins that are affected by the syndrome. Case presentation We report the cases of 16-year-old monozygotic twin boys who both suffered from Kleine-Levin syndrome. In both cases, the onset of the first episode was preceded by an influenza infection. During symptomatic periods they slept for the entire day except for meals and bathroom visits. Actimetry recordings revealed that during symptomatic periods, daily activity was lower than that of asymptomatic periods, on the other hand, activity during the night was significantly higher in symptomatic periods than asymptomatic periods. Polysomnography (PSG) data during symptomatic periods revealed a decrease in sleep efficiency. Human leukocyte antigen (HLA) typing revealed no DQB1*02 loci. They were administered lithium carbonate but the beneficial effect was limited. Conclusions Our observations suggest that Kleine-Levin syndrome may be due to genetic and autoimmune processes, although etiologic relationship to specific HLA type remains controversial.
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Affiliation(s)
- Taro Ueno
- Institute of Molecular Embryology and Genetics, Kumamoto University, Honjo, Kumamoto, 860-0811, Japan
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22
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Abstract
There is a strong association between sleep-related problems and neurologic diseases. Neurologic diseases of the CNS can directly cause sleep problems when sleep-wake mechanisms associated with the ascending reticular activating system are involved. The major sleep disorders associated with neurologic problems are outlined in the International Classification of Sleep Disorders, 2nd edition, as hypersomnias of central origin, sleep-related breathing disorders, the insomnias, circadian rhythm sleep disorders, sleep-related movement disorders, parasomnias, and sleep-related epilepsy. In a patient with CNS disease and excessive sleepiness, sleep-related breathing disorders should be a first concern, given the known association between obstructive sleep apnea (OSA) and cerebrovascular disease and the potential confounding effects that OSA might have on an otherwise compromised ischemic CNS penumbra. A basic knowledge of the anatomy and physiology of the sleep-wake mechanisms provides a rationale for pharmacologic intervention. Nonpharmacologic treatments are also important, especially when sleep-related breathing disorders are a concern. In addition, as patients with neurologic diseases are often prone to the adverse effects of many medications, the specific treatment regimen for any given individual should always include good sleep hygiene practices that use cognitive behavioral therapy.
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Affiliation(s)
- Mark Eric Dyken
- Department of Neurology, Division of Sleep Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA.
| | - Adel K Afifi
- Department of Pediatrics, Division of Pediatric Neurology, Behavior, and Development, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA
| | - Deborah C Lin-Dyken
- Department of Pediatrics, Division of Pediatric Neurology, Behavior, and Development, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA
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Billiard M, Jaussent I, Dauvilliers Y, Besset A. Recurrent hypersomnia: A review of 339 cases. Sleep Med Rev 2011; 15:247-57. [PMID: 20970360 DOI: 10.1016/j.smrv.2010.08.001] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 08/06/2010] [Accepted: 08/06/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Michel Billiard
- Department of Neurology, Gui de Chauliac Hospital, 80 Avenue Augustin Fliche, 34295 Montpellier cedex 5, France.
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Körtner K, Hansen M, Danker-Hopfe H, Neuhaus A, Jockers-Scherübl M. Persistent deficits of visual recall in Kleine–Levin syndrome. J Clin Neurosci 2011; 18:439-40. [PMID: 21236684 DOI: 10.1016/j.jocn.2010.07.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 05/16/2010] [Accepted: 07/24/2010] [Indexed: 10/18/2022]
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Affiliation(s)
- Michel Billiard
- Department of Neurology, Gui de Chauliac Hospital, Montpellier, France.
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Ramdurg S. Kleine-Levin syndrome: Etiology, diagnosis, and treatment. Ann Indian Acad Neurol 2010; 13:241-6. [PMID: 21264130 PMCID: PMC3021925 DOI: 10.4103/0972-2327.74185] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 07/25/2010] [Accepted: 08/09/2010] [Indexed: 11/13/2022] Open
Abstract
Kleine-Levin syndrome (KLS) is a rare sleep disorder mainly affecting teenage boys in which the main features are intermittent hypersomnolence, behavioral and cognitive disturbances, hyperphagia, and in some cases hypersexuality. Each episode is of brief duration varying from a week to 1-2 months and affected people are entirely asymptomatic between episodes. No definite cause has been identified, and no effective treatments are available even though illness is having well-defined clinical features. Multiple relapses occur every few weeks or months, and the condition may last for a decade or more before spontaneous resolution. In this study, PubMed was searched and appropriate articles were reviewed to highlight etiology, clinical features, and management of KLS. On the basis of this knowledge, practical information is offered to help clinicians about how to investigate a case of KLS, and what are the possible treatment modalities available currently for the treatment during an episode and interepisodic period for prophylaxis. Comprehensive research into the etiology, pathophysiology, investigation, and treatments are required to aid the development of disease-specific targeted therapies.
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Affiliation(s)
- Santosh Ramdurg
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
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Richard Y, Le Galudec M, Saint-André S, Planche P, Genestet S, Lazartigues A. [Kleine-Levin syndrome: a case report]. Encephale 2010; 36:28-32. [PMID: 20159193 DOI: 10.1016/j.encep.2008.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 11/06/2008] [Indexed: 11/19/2022]
Abstract
The purpose of this article is to report an original clinical case whose symptoms suggest a very peculiar pathology, because of its rarity, symptomatic expression and unclear etiopathogenesis: the Kleine-Levin Syndrome (KLS). During the regression of tonsillitis concomitant with an emotional shock, the 15-year-old patient exhibited a dramatic change in behaviour, at odds with his previous state, and accompanied by hypersomnia and confusion, megaphagia, irritability, hypersexuality and mood disorders. We observed a spontaneous and total regression of the symptoms after 12 days, except for the incomplete amnesia that proved to be persistent. Four months later, further to an ethylic drunkenness, the patient presented with a new and similar episode. The patient benefited from no medicinal treatment, even in the course of hypersomnia episodes and asymptomatic periods. After a clinical presentation of this patient, we will consider this case study from a more psychopathological angle by questioning the existence of a facilitating psychological profile. The discovery of an IQ equal to 86 from the scores of WISC-IV, and the identification of constructive visual difficulties made us suspect neurological disorders, but these abnormalities were not found during the completion of the Rey Complex Figure Test. The personality profile issued from the scores at the MMPI-A assessment was ranked as barely significant (type 2-4): indeed, it showed nothing specific to this patient. Literature data show that most of the patients presenting with a KLS have been seen by a psychiatrist at the time of the disease and diagnosed as suffering from hysteria, or schizophrenia, or bipolar disorders... Because of diagnostic wanderings, some patients have, hence, received inappropriate treatments. One should pay close attention to this very rare syndrome, on the border between neurology and psychiatry, since its diagnosis is essentially based on clinical features, and carefully think about the implementation of a medicinal treatment. This unique case seems unable to support our working hypothesis about the identification of a particular psychological profile in the KLS, but the question of an underlying fragility is still worth considering. We personally think that, even though links between the KLS and bipolar disorders have been suggested, this disease has to be considered as a separate entity.
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Affiliation(s)
- Y Richard
- Jeune équipe Ethique, Professionnalisation, Santé (JE 2535), université de Bretagne occidentale, UFR médecine et sciences de la santé, Service hospitalo-universitaire de psychiatrie de l'enfant et de l'adolescent, hôpital de Bohars, CHU de Brest, France.
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Abstract
Patients being evaluated in child psychiatry clinics for behavior and mood disturbances frequently exhibit daytime sleepiness. Conversely, patients being evaluated for hypersomnia by sleep specialists may have depressed mood or hyperactive and aggressive behavior. The etiology of daytime sleepiness in children and adolescents is diverse and includes inadequate sleep hygiene, obstructive sleep apnea, delayed sleep phase syndrome, idiopathic hypersomnia, periodic hypersomnia, narcolepsy, and mood disorders per se. Treatment of a sleep disorder can have a favorable impact on alertness and quality of life. A high index of suspicion for sleep problems should be maintained in children and adolescents with psychiatric disorders.
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MESH Headings
- Adolescent
- Child
- Comorbidity
- Cross-Cultural Comparison
- Cross-Sectional Studies
- Depressive Disorder, Major/diagnosis
- Depressive Disorder, Major/epidemiology
- Depressive Disorder, Major/psychology
- Diagnosis, Differential
- Disorders of Excessive Somnolence/diagnosis
- Disorders of Excessive Somnolence/epidemiology
- Disorders of Excessive Somnolence/etiology
- Disorders of Excessive Somnolence/psychology
- Health Surveys
- Humans
- Idiopathic Hypersomnia/diagnosis
- Idiopathic Hypersomnia/epidemiology
- Idiopathic Hypersomnia/psychology
- Mental Disorders/diagnosis
- Mental Disorders/epidemiology
- Mental Disorders/psychology
- Narcolepsy/diagnosis
- Narcolepsy/epidemiology
- Narcolepsy/psychology
- Patient Care Team
- Referral and Consultation
- Risk Factors
- Sleep Apnea, Obstructive/diagnosis
- Sleep Apnea, Obstructive/epidemiology
- Sleep Apnea, Obstructive/psychology
- Sleep Disorders, Circadian Rhythm/diagnosis
- Sleep Disorders, Circadian Rhythm/epidemiology
- Sleep Disorders, Circadian Rhythm/psychology
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Affiliation(s)
- Suresh Kotagal
- Department of Neurology, Division of Child Neurology, The Center for Sleep Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Oliveira MM, Conti C, Saconato H, Fernandes do Prado G. Pharmacological treatment for Kleine-Levin Syndrome. Cochrane Database Syst Rev 2009:CD006685. [PMID: 19370648 DOI: 10.1002/14651858.cd006685.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Kleine-Levin Syndrome (KLS) is a rare disorder which mainly affects adolescent men. It is characterized by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behavior such as hypersexuality, and signs of dysautonomia.In 1990 the diagnostic criteria for Kleine-Levin Syndrome were modified in the International Classification of Sleep Disorders, where it was defined as a syndrome composed of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behavior.The etiology of Kleine-Levin Syndrome remains unknown and several treatment strategies have been used. Some medications have been reported to provide some benefit for the treatment of Kleine-Levin Syndrome patients, but because of the rarity of the condition no long-term follow-up therapies have yet been described. OBJECTIVES This review aimed to evaluate:1. whether pharmacological treatment for Kleine-Levin Syndrome is effective and safe; and 2. which drug or category of drugs is effective and safe. SEARCH STRATEGY We obtained relevant trials from the following sources: the Cochrane Epilepsy Group Specialized Register (1 December 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2007); MEDLINE (1966 to December 2007); EMBASE (1980 to December 2007); LILACS (1982 to December 2007); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies. SELECTION CRITERIA All randomized controlled trials (RCTs) and quasi-randomized controlled trials looking at pharmacological interventions for Kleine-Levin Syndrome. We included both parallel group and cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors (MO and CC) extracted the data reported in the original articles. MAIN RESULTS No studies met the inclusion criteria for this systematic review. AUTHORS' CONCLUSIONS Therapeutic trials of pharmacological treatment for Kleine-Levin Syndrome, with a double-blind, placebo-controlled design are needed.
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Wise MS, Arand DL, Auger RR, Brooks SN, Watson NF. Treatment of narcolepsy and other hypersomnias of central origin. Sleep 2008; 30:1712-27. [PMID: 18246981 DOI: 10.1093/sleep/30.12.1712] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The purpose of this paper is to summarize current knowledge about treatment of narcolepsy and other hypersomnias of central origin. METHODS The task force performed a systematic and comprehensive review of the relevant literature and graded the evidence using the Oxford grading system. This paper discusses the strengths and limitations of the available evidence regarding treatment of these conditions, and summarizes key information about safety of these medications. Our findings provide the foundation for development of evidence-based practice parameters on this topic by the Standards of Practice Committee of the American Academy of Sleep Medicine. RESULTS The majority of recent papers in this field provide information about use of modafinil or sodium oxybate for treatment of sleepiness associated with narcolepsy. Several large randomized, placebo-controlled studies indicate that modafinil and sodium oxybate are effective for treatment of hypersomnia due to narcolepsy. We identified no studies that report direct comparison of these newer medications versus traditional stimulants, or that indicate what proportion of patients treated initially with these medications require transition to traditional stimulants or to combination therapy to achieve adequate alertness. As with the traditional stimulants, modafinil and sodium oxybate provide, at best, only moderate improvement in alertness rather than full restoration of alertness in patients with narcolepsy. Several large randomized placebo-controlled studies demonstrate that sodium oxybate is effective for treatment of cataplexy associated with narcolepsy, and earlier studies provide limited data to support the effectiveness of fluoxetine and tricyclic antidepressants for treatment of cataplexy. Our findings indicate that very few reports provide information regarding treatment of special populations such as children, older adults, and pregnant or breastfeeding women. The available literature provides a modest amount of information about improvement in quality of life in association with treatment, patient preferences among the different medications, or patient compliance. CONCLUSION Several recent studies provide evidence that modafinil and sodium oxybate are effective for treatment of hypersomnia due to narcolepsy. No studies were identified that report direct comparison of these newer medications with traditional stimulants. Despite significant advances in understanding the pathophysiology of narcolepsy, we do not have an ideal treatment to restore full and sustained alertness. Future investigations should be directed toward development of more effective and better tolerated therapies, and primary prevention.
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Affiliation(s)
- Merrill S Wise
- Methodist Healthcare Sleep Disorders Center Memphis, Tennessee, USA
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Morgenthaler TI, Kapur VK, Brown T, Swick TJ, Alessi C, Aurora RN, Boehlecke B, Chesson AL, Friedman L, Maganti R, Owens J, Pancer J, Zak R. Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. Sleep 2008; 30:1705-11. [PMID: 18246980 DOI: 10.1093/sleep/30.12.1705] [Citation(s) in RCA: 273] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
These practice parameters pertain to the treatment of hypersomnias of central origin. They serve as both an update of previous practice parameters for the therapy of narcolepsy and as the first practice parameters to address treatment of other hypersomnias of central origin. They are based on evidence analyzed in the accompanying review paper. The specific disorders addressed by these parameters are narcolepsy (with cataplexy, without cataplexy, due to medical condition and unspecified), idiopathic hypersomnia (with long sleep time and without long sleep time), recurrent hypersomnia and hypersomnia due to medical condition. Successful treatment of hypersomnia of central origin requires an accurate diagnosis, individual tailoring of therapy to produce the fullest possible return of normal function, and regular follow-up to monitor response to treatment. Modafinil, sodium oxybate, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, and selegiline are effective treatments for excessive sleepiness associated with narcolepsy, while tricyclic antidepressants and fluoxetine are effective treatments for cataplexy, sleep paralysis, and hypnagogic hallucinations; but the quality of published clinical evidence supporting them varies. Scheduled naps can be beneficial to combat sleepiness in narcolepsy patients. Based on available evidence, modafinil is an effective therapy for sleepiness due to idiopathic hypersomnia, Parkinson's disease, myotonic dystrophy, and multiple sclerosis. Based on evidence and/or long history of use in the therapy of narcolepsy committee consensus was that modafinil, amphetamine, methamphetamine, dextroamphetamine, and methylphenidate are reasonable options for the therapy of hypersomnias of central origin.
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Shukla G, Bhatia M, Singh S, Goyal V, Srivastava T, Behari M. Atypical Kleine–Levin syndrome: Can insomnia and anorexia be features too? Sleep Med 2008; 9:172-6. [PMID: 17644478 DOI: 10.1016/j.sleep.2007.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 02/23/2007] [Accepted: 03/23/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Kleine-Levin syndrome is an uncommon disorder with recurrent episodes of hypersomnia, clearly associated with behavioral abnormalities like binge eating, hypersexuality and abnormal behavior. Many patients may not necessarily fulfill minimum criteria described for diagnosis. We aim to report such patients with atypical presentation resembling the Kleine-Levin syndrome. METHOD We evaluated all patients at our clinic who had episodic disturbance in sleep and/or appetite lasting a few days to weeks, not necessarily fulfilling the International Classification of Sleep Disorders (ICSD) criteria for a diagnosis of Kleine-Levin syndrome, over 4 years. All clinical details, especially regarding sleep, appetite and behaviour during episodes, about prior and co-existing illnesses were noted. All patients were investigated with brain magnetic resonance imaging (MRI), electroencephalogram (EEG) and some with polysomnography. RESULTS Eighteen patients (5 females, 13 males) ranging in age from 12 to 55 years (median 18 years) were included in the study. The median duration of symptoms was 1.5 years, and the median number of episodes in each patient was six. The range of episode length was 18-300 h with a mean of 91.2h. Fourteen patients had a history of hypersomnia, 3 had only insomnia and 3 had both during their episodes, while 5 patients reported hyperphagia, 11 reduced appetite and 2 no change in appetite. Ictal EEG revealed evidence of sleep, while polysomnography showed reduced rapid eye movement (REM) latency and normal sleep architecture during the episode. MRI was normal in all patients, except one who showed non-specific abnormalities. All patients showed improvement with carbamazepine. CONCLUSION There are many patients with episodic alteration in sleep, appetite and behaviour with a course and treatment response similar to the classical Kleine-Levin syndrome, who otherwise do not fit the classical description for diagnosis of this condition.
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Affiliation(s)
- Garima Shukla
- Department of Neurology, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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Abstract
Hypersomnia related to CNS disorders can be due to a variety of conditions. In this review, we discuss the diagnosis and treatment of narcolepsy with and without cataplexy, idiopathic hypersomnia, recurrent hypersomnia, and related illnesses. Research has provided insight into the underlying etiologies of these disorders, such as the genetic influences on disease development and the fundamental role of hypocretins in narcolepsy. We define the current utility of diagnostic testing, including sleep studies, neuroimaging techniques, and laboratory investigations. New treatment options for hypersomnia are discussed.
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Affiliation(s)
- Timothy J Young
- Sleep Disorders Center, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA
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35
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Cheung G. Posttraumatic Kleine-Levin syndrome. Gen Hosp Psychiatry 2006; 28:443-5. [PMID: 16950384 DOI: 10.1016/j.genhosppsych.2006.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 03/29/2006] [Accepted: 03/29/2006] [Indexed: 11/24/2022]
Affiliation(s)
- Gary Cheung
- Department of Mental Health Services for Older People, Waikato District Health Board, PO Box 1372, Hamilton 2001, New Zealand
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Arnulf I, Zeitzer JM, File J, Farber N, Mignot E. Kleine-Levin syndrome: a systematic review of 186 cases in the literature. ACTA ACUST UNITED AC 2005; 128:2763-76. [PMID: 16230322 DOI: 10.1093/brain/awh620] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Kleine-Levin syndrome (KLS) is a rare disorder with symptoms that include periodic hypersomnia, cognitive and behavioural disturbances. Large series of patients are lacking. In order to report on various KLS symptoms, identify risk factors and analyse treatment response, we performed a systematic review of 195 articles, written in English and non-English languages, which are available on Medline dating from 1962 to 2004. Doubtful or duplicate cases, case series without individual details and reviews (n = 56 articles) were excluded. In addition, the details of 186 patients from 139 articles were compiled. Primary KLS cases (n = 168) were found mostly in men (68%) and occurred sporadically worldwide. The median age of onset was 15 years (range 4-82 years, 81% during the second decade) and the syndrome lasted 8 years, with seven episodes of 10 days, recurring every 3.5 months (median values) with the disease lasting longer in women and in patients with less frequent episodes during the first year. It was precipitated most frequently by infections (38.2%), head trauma (9%), or alcohol consumption (5.4%). Common symptoms were hypersomnia (100%), cognitive changes (96%, including a specific feeling of derealization), eating disturbances (80%), hypersexuality (43%), compulsions (29%), and depressed mood (48%). In 75 treated patients (213 trials), somnolence decreased using stimulants (mainly amphetamines) in 40% of cases, while neuroleptics and antidepressants were of poor benefit. Only lithium (but not carbamazepine or other antiepileptics) had a higher reported response rate (41%) for stopping relapses when compared to medical abstention (19%). Secondary KLS (n = 18) patients were older and had more frequent and longer episodes, but had clinical symptoms and treatment responses similar to primary cases. In conclusion, KLS is a unique disease which may be more severe in female and secondary cases.
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Affiliation(s)
- I Arnulf
- Stanford University Center for Narcolepsy, Palo Alto, CA, USA.
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