Case Report of Secondary Narcolepsy

Case Report of Secondary Narcolepsy Title of the article: â€Å" Case Report of Secondary Narcolepsy presenting as self-inflicted genital injury † Abstract: Primary Narcolepsy is a sleep disorder with classical presentation showing tetrad of excessive daytime sleepiness, cataplexy, sleep paralysis, and Hypnogogic hallucinations. Some conditions that result in secondary narcolepsy include traumatic brain injury, tumors, and stroke. [1] A rare case of secondary narcolepsy was seen in a patient with self-inflicted genital injury. A 30 year old male was referred to Psychiatry from Surgery for a self-inflicted incised wound on hydrocoele. Since last 1 year, he had multiple episodes of — 1. Sudden falls while working 2. Sleep during daytime often at unusual places 3. Periods of unresponsiveness during which he was aware but unable to move. During hospital stay, daytime somnolence, sleep paralysis and cataplexy were noted several times, but hallucinations were not consistently reported. Based on DSM-IV-TR N arcolepsy was diagnosed. Possible reasons for genital injury were 1. To remove fluid from swelling 2. Under sleep paralysis 3. Under Hypnogogic hallucinations. Patient’s 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 decades 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 [D1] :Secondary narcolepsy is rare and sometimes can be missed to diagnose. Such rare presentation of secondary narcolepsy helps in diagnosing other cases of self-inflicting injuries. Introduction: [D2] Narcolepsy is neither a type of epilepsy nor a psychogenic disturbance. It is an abnormality of the sleep mechanisms specifically, REM-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, generally before the age of 30. The disorder either progresses slowly 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 have 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]. There are no genetic tests currently available for clinical use to make a positive diagnosis of narcolepsy. Genetic testing may correlat e best to narcolepsy when there is already clear cataplexy. [4]. Supporting the evidence for an environmental influence is the fact that the disease is not apparent at birth, but instead commonly 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 produce 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 reduced in patients with severe TBI. This observation highlights the often overlooked hy pothalamic 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 report s 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 .