Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorariums from Jazz Pharmaceuticals for a speaking engagements.)
The author reviews sleep-related manifestations in patients with multiple sclerosis and points out the intimate relationship between this condition, fatigue, and excessive daytime sleepiness. Several cases of symptomatic narcolepsy have been described in patients with multiple sclerosis raising the question of demyelinating plaques involving hypothalamic centers. Other studies have indicated that disruption of nocturnal sleep as well as circadian rhythm disorders may underlie fatigue responsive to sleep management. Case studies have described REM sleep behavior disorder in association with acute multiple sclerosis. There is growing evidence that sleep-related respiratory disturbance is common in patients with multiple sclerosis and that in general the condition is underdiagnosed. Sleep disorders are significant contributors to fatigue in multiple sclerosis, and this notion highlights the desirability of conducting an in-depth evaluation of sleep-related manifestations, which are commonly multifactorial in patients with multiple sclerosis.
Historical note and terminology
European reports published in the first half of the 20th century cite cases of multiple sclerosis associated with sleep attacks variously termed as narcolepsy, drowsiness, and deep sleep (Guillain and Alajouanine 1928; Grigioresco 1932). In 1949 the association between multiple sclerosis and narcolepsy was mentioned in a review and case presentations of narcolepsy (Drake 1949). Subsequently, cases of narcolepsy-cataplexy and multiple sclerosis (Berg 1963) and of familial multiple sclerosis with narcolepsy-cataplexy were reported (Ekbom 1966). Based on the presence of DR2 histocompatibility antigen in 2 patients with narcolepsy and multiple sclerosis, Younger and colleagues suggested a common inheritance for both conditions (Younger et al 1991). Other authors have indicated that sleep disturbance is relatively common in multiple sclerosis, suggesting a multifactorial etiology that ranges from depression to lesion site (Leo et al 1991). A polysomnographic study of 25 patients with definite multiple sclerosis showed significantly reduced sleep efficiency and more awakenings during sleep (Ferini-Strambi et al 1994). Periodic leg movements were found in 36% of patients compared to 8% in controls. Central sleep apnea was found in 2 patients. MRI of the brain showed a greater load of lesions in cerebellum and brainstem in patients with periodic leg movements.
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