Kleine-Levin syndrome: a cause of diagnostic confusion

An Update on Kleine-Levin Syndrome

Purpose of Review

Kleine-Levin syndrome (KLS) is a rare relapsing-remitting sleep disorder distinguished by recurrent periods of severe hypersomnia accompanied by cognitive, mood, and behavioral changes. This review focuses mainly on the most recent developments and articles concerning this illness in the preceding five years while attempting to provide a basic overview of KLS.

Recent Findings

Genetic links were reported in some patients with KLS, like variation in TRANK1 in a worldwide case-control genome-wide association in patients with KLS, in addition to several uncommon variations in the LMOD3 gene, some of which are likely to be pathogenic, discovered by linkage analysis and exome sequencing in a sizable Saudi Arabian family with KLS and a European cohort of KLS patients. Additionally, recent data indicate that the amplitude of the circadian active/rest cycles significantly decreased during hypersomnia attacks, but during asymptomatic periods, it did not differ significantly from the controls. Moreover, patients with KLS are at a higher risk of developing emerging psychiatric disorders during follow-up. Recent data also points to possible discoveries of diagnostic-potential dysregulated proteomic patterns in KLS. Finally, new data suggest that functional imaging studies are often abnormal in KLS both during and between episodes.

Summary

KLS is an uncommon, severe, and uniform illness. When it comes to the diagnosis and treatment of KLS, these characteristics offer both opportunities and challenges. Over the past five years, some promising work has appeared in genetics, functional imaging, and biomarker identification; nevertheless, these areas still need more focus to advance the detection and treatment of patients suffering from KLS.

Sleep disorders in children and adolescents

The scientific study of sleep and its disorders is essentially just a few decades old, but during that time impressive advances have been made in the biological knowledge of sleep. There has been recognition and treatment of a wide range of sleep disorders from which many people in all sections of the population suffer. The common adverse consequences of persistent sleep disturbance (at personal, educational, social and occupational levels) for members of the public at large have become clear (Dement & Mitler, 1993), as have the special risks of such problems to which certain groups are exposed – notably people with chronic psychiatric or physical disorders or learning disabilities.

Sleep disorders in children and adolescents†

Disordered sleep has long been recognised as both a consequence of psychiatric illness and a contributory factor to its development. Significant sleep disturbance occurs in about 25% of children and adolescents and 80% or more of children in high-risk groups; it often continues into adulthood. All psychiatrists should therefore be familiar with the principles of sleep medicine and the impact of sleep and its disorders. In this article, the relationship between sleep disorders and the breadth of child and adolescent psychiatry in particular is explored. The classification, aetiology and implications of sleep disorders are discussed, as well as the practicalities of screening, diagnosis and management, with a view to informing readers how accurate diagnosis, prevention and successful treatment of sleep disorders can benefit patients and their families.

Pharmacological treatment for Kleine-Levin syndrome

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.

Kleine-Levin Syndrome

Kleine-Levin syndrome is a rare recurrent hypersomnia associated with symptoms of behavioral and cognitive impairment. This article reviews common presenting symptoms, differential diagnosis, diagnostic workup, and potential treatment options. Current updates on functional imaging studies and long-term neuropsychological studies are reviewed.

Review: psychiatric and medical consequences of disordered sleep

OBJECTIVES

The aim of this article is to draw attention to the clinical importance of disordered sleep in psychiatry and to demonstrate the growing awareness of medical illness as a complication of disordered sleep. As background to these main objectives, some general points are made to illustrate present-day approaches to the common and often serious problem of sleep disturbance.

METHODS

The review is based on a literature search from which key publications were selected to illustrate, in turn, main connections between disordered sleep and psychiatric and medical conditions.

RESULTS

Many such connections are described. Throughout psychiatry, regarding patients whatever their age, these connections have implications for clinical assessment and management. Emphasis is placed on the risk of misdiagnosis of sleep disorders as psychiatric or medical conditions. Examples of this are provided. The growing evidence that disordered sleep can predispose to medical illness is discussed.

CONCLUSION

As the subject of sleep and its disorders is particular relevant in psychiatry, a working knowledge of modern sleep medicine is important in all branches of psychiatric and other medical practice as well as in clinical research.

Psychosis in a case of kleine-levin syndrome: a diagnostic challenge

Kleine-Levin syndrome (KLS) is a rare disorder of sleep diagnosed mainly on clinical grounds. It presents a unique diagnostic dilemma for neurologists and psychiatrists; especially due to a high risk of being diagnosed as a psychiatric condition like a mood disorder. However, there is literature available documenting the cooccurrence of psychiatric illnesses in patients diagnosed with KLS. The following case highlights the above points.

Kleine-Levin syndrome: a review

Kleine-Levin syndrome is a recurrent hypersomnia associated with symptoms of hyperphagia, hypersexuality, and cognitive impairment. This article reviews the current available research and describes common clinical symptoms, differential diagnosis, and acceptable workup and treatment. Although deficits have traditionally been thought to resolve between episodes, functional imaging studies and long-term neuropsychological testing in select patients have recently challenged this notion. This may suggest that Kleine-Levin syndrome is not as benign as previously considered.

Clinical and Polysomnographic Features of Kleine-Levin Syndrome: Case Series

Kleine-Levin Syndrome (KLS) is a rare disorder characterized intermittent hypersomnia, hyperphagia, hypersexuality, abnormal behaviors, and confusion. Patients are asymptomatic between episodes. The aim of this case series study was to determine the clinical features of patients with KLS and to compare the polysomnography (PSG) findings between symptomatic and asymptomatic periods. We compared the results of PSG investigations performed in symptomatic and asymptomatic periods in six patients diagnosed with KLS at Gulhane Military Medical Faculty Sleep Research Center between 1998 and 2005. The age at onset of KLS was approximately 18 years, the diagnosis delayed 2.67 years, hypersomnia episodes lasted approximately 11.5 days, until the correct diagnosis, the patients had experienced on average 5 episodes. Total sleep time in KLS patients during symptomatic period and stage 2 sleep percent was higher than in asymptomatic period. REM latency was shorter and stage 3 and REM percent was lower in asymptomatic period. The clinical features including the age of onset and episode duration are compatible with those from the previous studies. It was observed that the sleep architecture during symptomatic period was different from that in asymptomatic period.

Pharmacological treatment for Kleine-Levin syndrome

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.

Relationship between Kleine-Levin syndrome and upper respiratory infection in Taiwan

STUDY OBJECTIVES

In Kleine-Levin Syndrome (KLS), new episodes of hypersomnia are often preceded by an acute flu-like syndrome or upper airway infection 3 to 5 days before onset. This study investigated the relationship between the occurrence of mild upper respiratory tract infections (URIs) in the general population and the occurrence and seasonality and hypersomnic episodes in KLS patients.

DESIGN

This investigation was a longitudinal clinical study. Based on data obtained from the National Health Research Institutes between 2006 and 2007, the timing of hypersomnic episodes in 30 KLS patients were compared with calendar reports of URI events, and the results compared with age-matched general Taiwanese population.

MEASUREMENTS

Clinical symptoms, physical examination, polysomnographic recording, SPECT study, and laboratory tests affirming KLS during both periods of hypersomnic attack and non-attack were collected. Every symptomatic episode was then followed up. The cross-correlation function (CCF) and bivariate correlations analysis were performed to see the relationship between KLS and URIs.

RESULTS

A positive finding of CCF analysis and significant bivariate correlations were found between KLS episodes and URI in the general population (r = 0.456*). In onset of hypersomnia, significant correlations existed among "acute upper respiratory infections" (r = 0.446*), "acute bronchitis and bronchiolitis" (r = 0.462*), and "pharyngitis and nasopharyngitis" (r = 0.548*) subtypes of infections. A positive correlation between higher reports of symptomatic hypersomnia and URI also existed in a given season. A positive nonsignificant trend for "allergic rhinitis" (r = 0.400) was also found.

CONCLUSION

The agent behind URI or its consequence (such as fever) is associated with increased incidence of KLS episodes and may explain periodic symptomatic recurrences.

Kleine-levin syndrome and idiopathic hypersomnia: spectrum disorders

Kleine-Levin syndrome (KLS) and idiopathic hypersomnia (IH) are primary sleep disorders of unknown etiologies, which often run a chronic course. The common core symptoms of these syndromes are hypersomnolence and sleep drunkenness, with periodic hypersomnolence and hyperphagia being the prominent symptoms of KLS. Psychiatric manifestations are common to both and include irritability, depression, apathy, inattention and poor concentration. Both disorders are diagnosed clinically and no specific laboratory investigation is available to confirm the diagnosis. We present a case highlighting the overlapping of the symptoms of KLS and IH, producing a complex clinical picture.

Kleine-Levine syndrome in an adolescent female and response to modafinil

Kleine-Levine Syndrome (KLS) is a disorder characterized by a triad of periodic hypersomnia, hyperphagia, and hypersexuality. KLS, although more common in young males, it has also been seen in females. Treatment options available for its management include mood stabilisers like lithium, stimulants like amphetamines, antidepressants and other options including electroconvulsive therapy. Modafinil is one of the new stimulant medications approved for narcolepsy. Herein, we report a young female with KLS and showing favorable response to modafinil. More data is required to establish the effectiveness of modafinil in this syndrome.

A case of Kleine-Levin syndrome with a complete and sustained response to carbamazepine

We describe a patient with Kleine-Levin syndrome who was initially misdiagnosed as having epilepsy and who achieved complete remission on carbamazepine treatment. A drug effect was established when symptoms recurred after carbamazepine taper and disappeared after reintroduction of the drug. Carbamazepine, a safer drug than lithium, can be a highly effective treatment in some patients with Kleine-Levin syndrome. This syndrome can sometimes be confused with epilepsy because of the episodic nature of the symptoms and the occasional response to anticonvulsants.

Pharmacological treatment for Kleine-Levin Syndrome

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.

Clinical diagnosis and misdiagnosis of sleep disorders

Sleep disorders are common in all sections of the population and are either the main clinical complaint or a frequent complication of many conditions for which patients are seen in primary care or specialist services. However, the subject is poorly covered in medical education. A major consequence is that the manifestations of the many sleep disorders now identified are likely to be misinterpreted as other clinical conditions of a physical or psychological nature, especially neurological or psychiatric disorders. To illustrate this problem, examples are provided of the various possible causes of sleep loss, poor quality sleep, excessive daytime sleepiness and episodes of disturbed behaviour at night (parasomnias). All of these sleep disorders can adversely affect mental state and behaviour, daytime performance or physical health, the true cause of which needs to be recognised by clinicians to ensure that appropriate treatment is provided. As conventional history taking in neurology and psychiatry pays little attention to sleep and its possible disorders, suggestions are made concerning the enquiries that could be included in history taking schedules to increase the likelihood that sleep disorders will be correctly identified.

The protean manifestations of childhood narcolepsy and their misinterpretation

Narcolepsy often begins in childhood but is infrequently recognized, partly because of its many manifestations that can be confused with other conditions. The clinical presentations of excessive sleepiness, cataplexy, hallucinatory phenomena, and sleep paralysis (not always occurring together) are very varied. The picture may be further complicated by the occurrence of automatic behaviour, memory and visual problems, and associated sleep disorders, as well as the psychological and social consequences of having narcolepsy. Not surprisingly, therefore, misinterpretation of the symptoms as primarily psychological, or otherwise physical, may well occur leading to inappropriate management including initial referral to psychiatric or educational rather than neurological or sleep disorder services. The wide-ranging and special features of childhood narcolepsy need to be appreciated by health care and other professionals as well as by parents.

Kleine-Levin syndrome: a systematic review of 186 cases in the literature

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.

Multiple sleep latency test and polysomnography in diagnosing Kleine-Levin syndrome and periodic hypersomnia

Kleine-Levin syndrome and periodic hypersomnia are often misdiagnosed initially because there is no objective test for these conditions. To determine the value of the Multiple Sleep Latency Test and polysomnography in this respect, the authors studied four patients with Kleine-Levin syndrome or periodic hypersomnia who had taken the Multiple Sleep Latency Test and undergone polysomnography during the symptomatic episode and/or during the asymptomatic interval. During but not between symptomatic episodes, the Multiple Sleep Latency Test revealed abnormal sleep latencies in all patients, and polysomnography revealed increased rapid eye movement propensity in one patient and a reduction in delta-sleep in two patients. In conclusion, the Multiple Sleep Latency Test and polysomnography are useful in diagnosing Kleine-Levin syndrome and periodic hypersomnia, especially when administered in a standardized fashion during and after the symptomatic period. The authors recommend that polysomnography and the Multiple Sleep Latency Test be performed no earlier than the second night after the onset of a symptomatic episode and the following day to reveal maximal hypersomnolence, and more than 2 weeks after a symptomatic episode to represent the asymptomatic interval.

Kleine-Levin syndrome. Clinical course, polysomnography and multiple sleep latency test. Case report

A case of Kleine-Levin syndrome, with chronic severe periodic hypersomnia is described in a 17-year-old female. The first episode started when she was 15 years old. The episodes were characterized by periodic hypersomnia accompanied by hyperphagia, lasting 5 days, and repeating at 28 to 60 day intervals. The severity of hypersomnia prevented her from attending school activities. Outside the hypersomnia periods, she was asymptomatic. EEG, brain computerized tomography and brain nuclear magnetic resonance were normal; all-night polysomnography, Multiple Sleep Latency Test (MSLT) and Epworth Sleepiness Scale (ESS) were within normal limits. During the period of hypersomnolence, polysomnography showed short sleep latency and short REM latency. MSLT mean sleep latency was 1.8 min; and REM period was present in one subtest; the ESS was markedly elevated.

Practitioner review: assessment and treatment of sleep disorders in children and adolescents

Sleep disorders in children are diverse in type, common, often serious in their effects yet neglected in professional education. They complicate many psychiatric disorders and can cause various cognitive and behavioural problems as well as more widespread difficulties in the family as a whole. Accurate assessment allows an appropriate choice from the various types of treatments that are now available but often under used. Diagnostic points and treatment approaches are outlined for the three main categories of childhood sleep disorder: sleeplessness; excessive sleepiness; and episodic disturbances related to sleep (parasomnias). The need for more widespread awareness of and provision for sleep disorders is emphasized.