Monday, June 3, 2019

Case Report of Secondary Narcolepsy

Case Report of Secondary NarcolepsyTitle of the article Case Report of Secondary Narcolepsy presenting as self-inflicted genital crack Abstract Primary Narcolepsy is a sleep unhinge with classical launching showing tetrad of excessive mean solar day sleepiness, cataplexy, sleep paralysis, and depressant hallucinations. rough conditions that result in alternate narcolepsy complicate traumatic brain injury, tumors, and stroke. 1A rare case of secondary narcolepsy was seen in a unhurried with self-inflicted genital injury. A 30 year old priapic was referred to Psychiatry from Surgery for a self-inflicted incised wound on hydrocoele. Since last 1 year, he had multiple episodes of 1. abrupt waterfall while on the job(p) 2. Sleep during daytime often at unusual places 3. Periods of unresponsiveness during which he was aware save unable to move. During hospital stay, daytime somnolence, sleep paralysis and cataplexy were noted several times, but hallucinations were not consi stently reported. Based on DSM-IV-TR Narcolepsy was diagnosed. Possible reasons for genital injury were 1. To remove fluid from extrusion 2. Under sleep paralysis 3. Under Hypnogogic hallucinations. Patients EEG was normal. MRI brain showed Gliosis at cervico-medullary junction.MRI spine was advised to examine the cervico-vertebral junction but patient was lost to follow-up. But from history and investigations, it was concluded that he had secondary narcolepsy due to traumatic brain injury.Narcolepsy typically begins in the 2nd and 3rd cristals of life and negatively impacts the quality of life of affected patients. Diagnosis relies on patient history and objective data gathered from polysomnography and multiple sleep latency testing. Treatment focuses on symptom relief through medication, education, and behavioural modification.Key-words Cataplexy Narcolepsy Polysomnography Self inflicted injury,Key Messages D1Secondary narcolepsy is rare and sometimes grass be missed to diagno se. Such rare presentation of secondary narcolepsy helps in diagnosing other cases of self-inflicting injuries. IntroductionD2 Narcolepsy is n both a type of epilepsy nor a psychogenic disturbance. It is an abnormality of the sleep mechanisms specifically, paradoxical sleep-inhibiting mechanisms and it has been studied in dogs, sheep, and humans. Narcolepsy can occur at any age, but it most frequently begins in adolescence or young adulthood, worldwidely before the age of 30. The disorder either progresses belatedly or reaches a plateau that is maintained throughout life.2. The prevalence of narcolepsy varies across countries and with different ethnic groups, and so the exact prevalence is not known. Prevalence estimates mother been reported to be between 168 and 799 per 100,000 in most studies, although Japanese studies have indicated a higher prevalence of 1600 per 100,000.2,3. in that respect are no genetic tests shortly available for clinical use to make a positive diagnos is of narcolepsy. Genetic testing may correlate best to narcolepsy when there is already lightheaded cataplexy.4.Supporting the evidence for an environmental influence is the fact that the disease is not apparent at birth, but instead unremarkably has its onset during the second decade of life. Additionally, there are apparent precipitating factors such as head trauma, infection, and changes in sleep-waking habits that have been identified in some cases.6 Chronic, daytime sleepiness is a major, disabling symptom for many patients with traumatic brain injury (TBI), but thus far, its aetiology is not well understood. Extensive loss of the hypothalamic neurons that pay back the wake-promoting neuropeptide hypocretin (orexin) causes the severe sleepiness of narcolepsy, and partial loss of these cells may contribute to the sleepiness of Parkinson disease and other disorders. One study has found that the number of hypocretin neurons is significantly cut down in patients with severe TB I. This observation highlights the often all overlooked hypothalamic injury in TBI and provides new insights into the causes of chronic sleepiness in patients with TBI.7 Amphetamine usage has been associated with addiction, psychosis and self-injurious behaviour. There are reports on two patients who severely and repeatedly mutilated their own genitalia while intoxicated on amphetamines and consider possible diagnostic aetiologies.8 genital mutilation is common in males compared to females.9 But narcolepsy presenting as self inflicted genital injury has not been reported so far. That is why this is a rare case.Case HistoryD3 A case of secondary narcolepsy was seen in a patient presenting as self-inflicted genital injury. A 30 year old Hindi speaking illiterate male was referred to Psychiatry from Surgery for a self-inflicted incised wound on hydrocele. After primary wound closure at surgical side, patient was taken get rid of to Psychiatry for detailed assessment. When detailed hi story was obtained from patients elder brother and father, it was found that since last 1 year, he had multiple episodes of sudden falls while working at kitchen as he was a cook. He used to sleep during daytime often at unusual places like in the courtyard, once over the road and sometimes in bathroom. Patient also had periods of unresponsiveness during which he was aware but unable to move himself even on painful stimulation. During hospital stay, daytime somnolence, sleep paralysis and cataplexy were noted several times, but hallucinations were not consistently reported. Based on DSM-IV-TR Narcolepsy was diagnosed. Possible reasons for genital injury were 1. To remove fluid from swelling 2. Under sleep paralysis 3. Under Hypnogogic hallucinations. Patients EEG was normal. MRI brain showed Gliosis at cervico-medullary junction.MRI spine advised to examine the cervico-vertebral junction but patient was lost to follow-up. But from history and investigations, it was concluded that he had secondary narcolepsy due to traumatic brain injuryDiscussion Narcolepsy is a condition characterized by excessive sleepiness, as well as auxiliary symptoms that represent the intrusion of aspects of REM sleep into the wakingstate. The sleep attacks of narcolepsy represent episodes of irresistible sleepiness, leading to perhaps 10 to 20 minutes of sleep, after which the patient feels refreshed, at least briefly. They can occur at inappropriate times (e.g., while eating, talking, or driving and during sex). The REM sleep accommodates Hypnogogic and Hypnopompic hallucinations, cataplexy, and sleep paralysis. The appearance of REM sleep within 10 minutes of sleep onset (sleep-onset REM periods) is also considered evidence of narcolepsy. The disorder can be dangerous because it can lead to automobile and industrial accidents.Other symptoms include Hypnogogic or Hypnopompic hallucinations, which are vivid perceptual experiences, either auditory or visual, occurring at sleep onset or on awakening. Patients are often momentarily frightened, but within a minute or two they return to an entirely normal frame of mind and are aware that nothing was actually there. Here patient had symptoms of narcolepsy after head injury and patient himself injured his scrotum with sharp blade for which he had no clear memory and there was no history suggestive of epilepsy so diagnosis of secondary narcolepsy presenting as self-inflicted genital injury was considered.In this case, patient showed clinical features of narcolepsy as diagnosed by DSM- IV which was secondary type as there was history of multiple falls and MRI brain showed gliosis. But in this case, unusual presentation was genital self-inflicted injury.Possible reasons for genital injury areAutomatic behavior.Acting on Hypnogogic/Hypnopompic hallucinations.Due to impaired cognitive function/ judgment due to long-standing Narcolepsy.No cure exists for narcolepsy, but symptom management is possible. A regimen of forced nap s at a regular time of day occasionally helps patients with narcolepsy and, in some cases, the regimen alone, without medication, can almost cure the condition. When medication is required, stimulants are most commonly used.10Although drug therapy is the treatment of choice, the overall therapeutic approach should include scheduled naps, lifestyle adjustment, psychological counselling, drug holidays to reduce tolerance, and careful monitoring of drug refills, general health, and cardiac status.ReferencesD41. Narcolepsy Clinical features, co-morbidities treatment Jeremy Peacock Ruth M. Benca Indian J Med Res 131, pp 338-349 20102. Longstreth WT, Jr., Koepsell TD, Ton TG, Hendrickson AF, van Belle G. The epidemiology of narcolepsy. Sleep 2007 30 13-26.3.Tashiro T, Kanbayashi T, Iijima S, Hishakawa Y. An epidemiological study on prevalence of narcolepsy in Japanese. J Sleep Res 1992 (Suppl 1) 228.4. Bourgin P, Zeitzer JM, Mignot E. CSF hypocretin-1 assessment in sleep and neurologi cal disorders. Lancet Neurol 2008 7 649-625. Krahn LE, Pankratz VS, Oliver L, Boeve BF et al, Narcoleptic and schizophrenic hallucinations. Implications for differential diagnosis and pathophysiology. Eur J Health Econ. 2002 3 (Suppl 2) S94-8.6. Bourgin P, Zeitzer JM, Mignot E. CSF hypocretin-1 assessment in sleep and neurological disorders. Lancet Neurol 2008 7 649-62.7. Christian R. Baumann MD, Claudio L. Bassetti MD, Philipp O. Valko MD, Johannes Haybaeck MD,et al Loss of hypocretin (orexin) neurons with traumatic brain injury.8. Joshua A. Israel and Kewchang, lee(prenominal) Article first published online Amphetamine usage and genital self-mutilation. 2002 DOI10.1046/j.1360-0443.2002.00230.x9. MartinT.GattazW.F, Psychiatric Aspects of Male Genital Self-Mutilation.Psychopathology 24170178,1991.10. synopsis of psychiatry tenth editionCase series of genital mutilation The Journal of Urology150(4)1143-1146 1993.D11 Provide appropriate messages of about 35-50 words to be printed in centre boxD21 Please include why this case is unique. If it is rare, how rare, how many cases have been reported.D31 Include the tables/charts at appropriate places in the text it self. Do not include images in the text. Mark the conduct of insertion of images (e.g. Figure 1) along with the legends. Send the images separately as jpeg files (not larger than 100 kb each)D41 Follow the punctuation marks carefully. Do not include unnecessary bibliographic elements such as issue number, month of publication, etc. Include names of six authors followed by et al if there are more than than six authors.

No comments:

Post a Comment

Note: Only a member of this blog may post a comment.