Case Report of Secondary Narcolepsy

gaffe Report of supplementary NarcolepsyTitle of the article effort Report of Secondary Narcolepsy presenting as self-inflicted venereal hurt Abstract Primary Narcolepsy is a intermission disorder with classical presentation showing tetrad of excessive twenty-four hours pauseiness, cataplexy, balance paralysis, and somnific hallucinations. Some conditions that result in junior-grade narcolepsy accept traumatic brain injury, tumors, and stroke. 1A ancient case of secondary narcolepsy was seen in a uncomplaining with self-inflicted genital injury. A 30 year ageing male was referred to Psychiatry from Surgery for a self-inflicted engraved wound on hydrocoele. Since last 1 year, he had multiple episodes of 1. Sudden falls eon working 2. Sleep during daytime often at unusual places 3. Periods of deadness during which he was sensible just unable to move. During hospital stay, daytime somnolence, sleep paralysis and cataplexy were noned several times, scarce hallucin ations were not consistently reported. found on DSM-IV-TR Narcolepsy was diagnosed. Possible reasons for genital injury were 1. To dispatch fluid from inflation 2. Under sleep paralysis 3. Under depressant hallucinations. Patients EEG was normal. magnetic resonance imaging brain showed Gliosis at cervico-medullary junction.MRI spine was advised to discover the cervico-vertebral junction but tolerant was lost to follow-up. exactly from history and investigations, it was cogitate that he had secondary narcolepsy due to traumatic brain injury.Narcolepsy typically begins in the 2nd and third decades of life and negatively impacts the quality of life of affected patients. Diagnosis relies on patient history and objective data ga in that locationd from polysomnography and multiple sleep latency testing. Treatment focuses on symptom relief through medication, education, and behavioral modification.Key- address Cataplexy Narcolepsy Polysomnography Self inflicted injury,Key Messages D1Secondary narcolepsy is rare and sometimes erect be missed to diagnose. Such rare presentation of secondary narcolepsy helps in canvass new(prenominal) cases of self-inflicting injuries. IntroductionD2 Narcolepsy is n either a type of epilepsy nor a psycho contractable 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 untried 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 contrastive ethnic groups, and so the exact prevalence is not kn consume. Prevalence estimates confound been reported to be between 168 and 799 per 100,000 in most studies, although Japanese studies relieve oneself indicated a higher prevalence of 1600 per 100,000.2,3. in that respect are no genetic tests currently available for clinical use to make a ordained diagnosis of narcolepsy. Genetic testing may correlate best to narcolepsy when there is already clear cataplexy.4.Supporting the evidence for an environmental influence is the situation that the disease is not apparent at birth, but instead unremarkably has its onset during the second decade of life. Additionally, there are apparent precipitate 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 umteen 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 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 symptomatic aetiologies.8 venereal 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 surgic al side, patient was taken transfer to Psychiatry for expand opinion. When detailed history 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 path 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 pat ient was lost to follow-up. But from history and investigations, it was concluded that he had secondary narcolepsy due to traumatic brain injury raillery Narcolepsy is a condition characterized by excessive sleepiness, as well as auxiliary symptoms that award 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 proceeding of sleep, afterwardward which the patient feels refreshed, at least briefly. They can occur at unfitting times (e.g., while eating, talking, or driving and during sex). The REM sleep includes Hypnogogic and Hypnopompic hallucinations, cataplexy, and sleep paralysis. The appearance of REM sleep within 10 time of days 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. otherwise symptoms include Hypnogogic or Hypnopompic hallucina tions, 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 forefront 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 apocalyptic 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 damage cognitive function/ judgment due to long-st anding Narcolepsy.No cure exists for narcolepsy, but symptom management is possible. A fodder of forced naps 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 unremarkably used.10Although dose therapy is the treatment of choice, the overall therapeutic approach should include schedule 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 reticuloendothelial system 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 epidemiologic study on prevalence of narcolep sy in Japanese. J Sleep Res 1992 (Suppl 1) 228.4. Bourgin P, Zeitzer JM, Mignot E. CSF hypocretin-1 assessment in sleep and neurological 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 Article first print 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 10th editionCase series of genital mutil ation 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 engineer of insertion of images (e.g. Figure 1) along with the legends. Send the images separately as jpeg files (not large than 100 kb each)D41 Follow the punctuation marks carefully. Do not include unnecessary bibliographic elements such as issue number, calendar month of publication, etc. Include names of six authors followed by et al if there are more than six authors.