Patient Case 2

A 67-year-old man was evaluated in the sleep clinic at this hospital because of odd behaviors during sleep, daytime sleepiness, and apnea detected on a home sleep study. Three years before the current evaluation, the patient’s wife noticed that the patient had vocalizations, including talking and yelling, while sleeping. He also had thrashing movements while sleeping; he fell out of bed more than once and inadvertently hit his wife during these movements. Two years before the current evaluation, the patient’s wife noticed that the patient had prolonged episodes of daytime sleepiness. During the episodes, he appeared to fall asleep while sitting up and was unresponsive to shaking and loud voices; several hours later, he returned to normal interaction without any intervention. The daytime sleepiness was intermittent and fluctuated in severity. Four months before the current evaluation, the patient fell asleep while washing dishes. This resulted in a fall and unstable C1 spinal fracture, which required urgent surgical repair. After the surgical repair, melatonin and trazodone were prescribed for insomnia, and abnormal movements during sleep abated. However, vocalizations during sleep — including singing, talking, and expression of fear and anger in the context of upsetting dreams — continued and were most prominent in the early morning hours. The patient also had a motor neurologic syndrome that had started before the onset of sleep symptoms, approximately 3.5 years before the current evaluation. Symptoms included progressive gait imbalance with falls, hand clumsiness, hoarse voice, and dysphagia. Serial neurologic examinations, performed over a 3-year period by multiple neuromuscular specialists, revealed slow progression of generalized fasciculations and the development of bulbar hyperreflexia, postural instability, and hypophonia, although strength in the arms and legs remained intact. Serial electromyography revealed progressive and widespread involvement of muscles showing chronic reinnervation changes, including eventual involvement of craniobulbar muscles (tongue and masseter muscles).

Case study Reference: Videnovic, A., Babu, S., Zhao, B., Reda H. M., & Linnoila, J. J.. (2022). Case 1-2022: A 67-Year-Old Man with Motor Neuron Disease and Odd Behaviors during Sleep. The new england journal of medicine. https://doi.org/10.1056/NEJMcpc2115844

Date of Presentation: 01/13/2022

67M Employed

Treatment Names	Chance of Remission
Induction therapy with Intravenous Cyclophosphamide	86%
3 doses Cyclophosphamide (q. month) + 1 tapered Oral Prednisone course	75%
Intravenous Methylprednisolone	70%
Oral Doxycycline	62%

Treatment Names

Chance of Remission

Induction therapy with Intravenous Cyclophosphamide

86%

3 doses Cyclophosphamide (q. month) + 1 tapered Oral Prednisone course

75%

Intravenous Methylprednisolone

70%

Oral Doxycycline

62%

Patient Information

Basic Information

DX	Cerebral amyloid angiopathy–related inflammation.	SX	Cognitive impairment, headache, and memory loss
FH	A major depressive episode	ALGY	Allergic to Amoxicillin–clavulanate with an unknown reaction

Current Medications

Atorvastatin, Levothyroxine, Sertraline, Vitamin B12, and Cholecalciferol. ➕

The patient had a history of poliomyelitis in childhood, with residual mild weakness in the left leg; vitamin B12 deficiency, which had been corrected; and hypothyroidism.

Other Information

Former smoker with a 40 pack-year history, and she had consumed four alcoholic beverages per week before the onset of the current illness.

Examination Result

6 Examination Results: ➕

• The temperature: 36.7°C,
• blood pressure: 105/51 mm Hg,
• heart rate: 56 beats per minute,
• respiratory rate: 16 breaths per minute,
• oxygen saturation: 96% while she was breathing ambient air.
• body-mass index (the weight in kilograms divided by the square of the height in meters): 32.4.

Literature Evidence

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Below table displays the matchable literatures from PubMed and Google Scholar filtered by patient's SX.

Literature Names	Year
There is evidence that migraine is associated with cognitive impairment years before a migraine diagnosis. In young and middle-aged adults, migraine is associated with deficits in attention, executive function, processing speed, and memory. It is unlikely that migraine is associated with dementia.	(2022)
Elevated intracranial pressure headache and emotional distress can contribute to reduced cognitive performance and increased self monitoring.	(1997)
Cognitive impairment is a common symptom in patients with stress-related exhaustion, and is most pronounced in executive function, attention span, and working memory. The severity of burnout symptoms is related to poorer performance on tests of learning and memory.	(2012)
The RBMT can be used to accurately diagnose mild cognitive impairment in patients. However, prospective memory tasks are not useful for detecting these patients.	(2005)

Patient Case 2

DST Recommendations: Aifred Health

Patient Information

Literature Evidence