Annals of Indian Academy of Neurology
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Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 537-538

Secondary narcolepsy masquerading as obstructive sleep apnea

Department of Neurology, St Stephen's Hospital, New Delhi, India

Date of Submission08-Jan-2019
Date of Acceptance14-Mar-2019
Date of Web Publication25-Oct-2019

Correspondence Address:
Dr. Sachin Sureshbabu
Department of Neurology, St Stephen's Hospital, New Delhi - 110 054
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aian.AIAN_19_19

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How to cite this article:
Sureshbabu S, Asranna A, Peter S, Chindripu S, Mittal GK. Secondary narcolepsy masquerading as obstructive sleep apnea. Ann Indian Acad Neurol 2019;22:537-8

How to cite this URL:
Sureshbabu S, Asranna A, Peter S, Chindripu S, Mittal GK. Secondary narcolepsy masquerading as obstructive sleep apnea. Ann Indian Acad Neurol [serial online] 2019 [cited 2020 Aug 12];22:537-8. Available from:


Secondary causes of narcolepsy are attributable to brain insults like trauma, infections, stroke, and demyelination.[1],[2] Though the pathogenesis is unclear, current thinking proposes that the wakefulness promoting neurons of lateral hypothalamus are destroyed by autoimmune mechanisms triggered by infection, injury or vaccination.[3] There are studies that have shown associations between narcolepsy and streptococcal infections [4] or H1N1 epidemics.[5] We report a case of narcolepsy without cataplexy which developed as a consequence of probable Dengue virus infection and was initially mistaken for obstructive sleep apnea. (OSA).

A 26-year-old man presented with excessive sleepiness and lethargicness for the past one year. Symptoms were preceded by a febrile illness for which he was evaluated and diagnosed to have dengue infection based on clinical features, thrombocytopenia and serology. He made a clinical recovery over 7-10 days after which he noted progressive symptoms of excessively sleepiness. Contrast enhanced MRI brain was done to rule out possibility of encephalitis and was found to be normal. Otorhinolaryngology evaluation showed a deviated nasal septum and features of chronic sinusitis for which he underwent functional endoscopic sinus surgery (FESS). He reported no symptomatic benefit and hence an overnight polysomnography (PSG) was planned. PSG showed findings of OSA with an apnoea-hypopnea index (AHI) of 24 and REM AHI of 40. After sleep endoscopy, patient was taken up for surgical management of OSA. However, his symptoms continued to worsen which prompted a neurology review. On further interrogation, he had excessive daytime sleepiness (EDS) without events suggesting cataplexy and sleep paralysis. Overnight PSG showed an AHI of four and sleep onset rapid eye movement sleep periods (SOREMPs). Multiple sleep latency testing (MSLT) revealed SOREMPs in all the five attempts at sleep [Figure 1]. He fulfilled the DSM-5 criteria for narcolepsy and can be categorised as narcolepsy type 2 based on the ICSD-3 criteria.
Figure 1: Representative polysomnogram of the patient during MSLT showing Sleep onset REM sleep

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A high index of suspicion is required to diagnose mono-symptomatic cases and incomplete presentations.[6] The presence of SOREMPs in MSLT makes the diagnosis unmistakable but this is not routinely undertaken in patients with excessive daytime sleepiness (EDS). The presence of respiratory events like apnoea and hypopnoea further distracts the treating physician from the primary disorder. The delay in diagnosis can be as high as 15 years as reported by Thorpy et al.[7] The present report highlights the high chance of misdiagnosis which can be far worse than delay in diagnosis in terms of unnecessary, expensive and at times harmful interventions the patients are subject to.

The role of infections and autoimmunity in the pathogenesis of the disorder is founded on indirect observations like temporal association with epidemics, detection of antibodies like ASO from patient sera and response to immunotherapy. The author (SSB) in a previous series of 13 patients with narcolepsy from India, did not discover any temporal association with infections or seasonal epidemics.[8] There is no reference of this aspect in the other major series from the country by Shukla et al.[9] In the wake of emerging infections and rising epidemics, this report evokes interest because of its clinical and epidemiological implications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Dauvilliers Y, Arnulf I, Mignot E. Narcolepsy with cataplexy. Lancet 2007;:499-511.  Back to cited text no. 1
Nishino S, Kanbayashi T. Symptomatic narcolepsy, cataplexy and hypersomnia, and their implications in the hypothalamic hypocretin/orexin system. Sleep Med Rev 2005;:269-310.  Back to cited text no. 2
Hallmayer J, Faraco J, Lin L, Hesselson S, Winkelmann J, Kawashima M, et al. Narcolepsy is strongly associated with the T-cell receptor alpha locus. Nat Genet 2009;41:708-11.  Back to cited text no. 3
Aran A, Lin L, Nevsimalova S, Plazzi G, Hong SC, Weiner K, et al. Elevated anti-streptococcal antibodies in patients with recent narcolepsy onset. Sleep 2009;32:979-83.  Back to cited text no. 4
Han F, Lin L, Warby SC, Faraco J, Li J, Dong SX, et al. Narcolepsy onset is seasonal and increased following the 2009 H1N1 pandemic in china. Ann Neurol 2011;70:410-7.  Back to cited text no. 5
Ruoff C, Rye D. The ICSD-3 and DSM-5 guidelines for diagnosing narcolepsy: Clinical relevance and practicality. Curr Med Res Opin 2016;32:1611-22.  Back to cited text no. 6
Thorpy MJ, Krieger AC. Delayed diagnosis of narcolepsy: Characterization and impact. Sleep Med 2014;:502-7.  Back to cited text no. 7
Sureshbabu S, Muniem A, Bhatia M. Diagnosis and management of narcolepsy in the Indian scenario. Ann Indian Acad Neurol [Internet] 2016;19:456-61. Available from:  Back to cited text no. 8
Shukla G, Goyal V, Srivastava A, Behari M, Gupta A. Clinical and polysomnographic characteristics in 20 North Indian patients with narcolepsy: A seven-year experience from a neurology service sleep clinic. Neurol India [Internet] 2012;60:75-8.  Back to cited text no. 9


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