A 63-year-old male carpenter (Chinese) suffered from EDS over the previous 3 years (2015). He was admitted to our hospital in 2018. Daytime sleepiness without obvious inducement. He can quickly fall asleep when he was working or watching TV, wake up a few minutes later, and relapse several times throughout the day. Accompanied by loss of muscular tension, cataplexy, can speak, but the words are fuzzy. No abnormality in breathing, defecation or urination, no limb convulsions, no headache, no vomiting, numbness of limbs or movement disturbance. Occurrence of disease was transient, a few seconds to several minutes can be alleviate. From time to time after waking up to find themselves unable to control their own body, unable to move, conscious, a few minutes can be alleviated. Mood is a bit poor, accompanied by bosom frosty, flustered, giddy body discomfort. He had no headaches, dizziness, paralysis, numbness, or convulsions. He had no past medical history of mental stimulation, head trauma, drug abuse, hypertension, or diabetes. His family and relatives had no similar EDS complaints. General examination showed no abnormalities of his heart, lungs, or abdomen. Neurological examination showed no positive sign. He was visited several hospital after April 2015: diagnosed as "sleep disorder", treated with "Nicergoline 10mg/day and Flupentixol and Melitracen Tablets (Deanxit) 2 tablets/day"; Diagnosed as "mixed anxiety and depression disorder, sleep disorder", treated with “Sulpiride 25 mg/day, Citalopram Hydrobromide Capsules 20 mg/day, Buspirone Hydrochloride Tablets 5 mg/day and Oxazepam Tablets 15 mg/ day”. No significant improvement were observed after treatment. He was admitted to our hospital in February 2018. Inpation for 15 days, outpatient follow-up for half a year.
Previous health status: Right eye was infected with herpes zoster virus in 2015. Denying the history of "heart disease", "coronary heart disease", "diabetes", "nephritis" and "cerebrovascular accident", denying the history of infectious diseases such as "hepatitis" and "tuberculosis", denying getting an influenza vaccine, denying the history of major surgical trauma, denying the history of blood transfusion and blood product application, denying the history of food and drug allergy.
The blood routine and biochemical examination were normal except: Triglyceride 2.53mmol/L↑, total cholesterol 5.37mmol/L↑, low-density lipoprotein cholesterol 3.88mmol/L↑,(hypersensitive) C-reactive protein 7.46mg/L↑. The serum was negative for antibodies against hepatitis C, syphilis, and Acquired Immune Deficiency Syndrome (AIDS). No abnormalities were found on head Magnetic Resonance Imaging (MRI). Plain Computed Tomography (CT) scan of the chest: 1. Fibrous calcification in the lower lobe of the left lung. 2. Aorta broadening, aortic wall and coronary artery calcification, and left ventricle slightly enlarged. 3. See the calcification of the right liver.
When evaluating the sleep and psychology status by standard assessment scales, he scored 17 on the Pittsburg sleep quality index, 22 on the Epworth sleepiness scale, 40 on the self-rating anxiety scale, and 69 on the self-rating depression scale. An overnight polysomnography (PSG) test was performed immediately after his admission. The PSG data indicated an abnormal sleep, which had a total duration of 431.5 minutes, sleep efficiency of 88.8%, sleep latency of 18.5 minutes, and the ratio of REM sleep that reached 23.3%. The ratio of I stage, II stage and III stage was 36.2%, 40.1% and 0.5%, respectively. The PSG data also indicated a good sleep breath, of which the apnea-hypopnea index was 2.7, the average oxygen saturation (SaO2) was 97%, and the minimum SaO2 was 91%. The day after the PSG night, multiple sleep latency tests (MSLT) were performed. The MSLT data showed two periods of sleep-onset rapid eyes movement period across 4 successive tests; the average sleep latency was 7.9 minutes, and the REM latency was 1.2 minutes.
According to the 3rd edition of the International Classification of Sleep Disorders (ICSD-3), we diagnosed the case as narcolepsy type 2. The ethics committee of the Hangzhou Seventh People’s Hospital approved the study.
After treatment (Treated with duloxetine hydrochloride enteric dissolution capsule (Cymbalta) 120mg after breakfast and clonazepam tablets 0.5mg before sleep, It was a little nauseous induced by Cymbalta at first), the patient’s EDS symptoms disappeared immediately. He scored 6 on the Epworth sleepiness scale, 7 on the Pittsburg sleep quality index, 36 on the self-rating anxiety scale, and 40 on the self-rating depression scale. During our follow-up 6 months later, he remained well with no complications.