1053 Narcolepsy in Tourette syndrome

Abstract

Introduction: Tourette syndrome is a chronic disorder with involuntary motor and vocal tics. Sleep problems are common due to increased tics and comorbid conditions like attention deficit hyperactivity disorder (ADHD) and anxiety. Medications to treat tics or insomnia can cause daytime sleepiness. Report of Case: A 14-year-old male presents with the complaint of excessive daytime sleepiness of more than 1-year onset. He has a past medical history of Tourette syndrome, ADHD, anxiety, depression, and adenotonsillectomy due to recurrent pharyngitis. He is homeschooled, and sleeps between 10 pm to 6 - 10 am every day. Naps >2 h every day. Snoring, gasping and sleep talking are reported. His Epworth sleepiness score was 24. He denied hallucinations or cataplexy. He denied alcohol/drug abuse, trauma, hospitalization or family history of narcolepsy. Physical exam was unremarkable except BMI 35.29 kg/m2. His differential included obstructive sleep apnea vs. narcolepsy. His extended release guanfacine to treat tics was stopped, and Neurology held off starting an antidepressant for the sleep studies. The in-lab polysomnography showed an Apnea-Hypopnea Index = 0.6/h, Total Sleep Time = 7.8 h, Sleep Latency = 1 min, REM Latency = 47.5 min, Sleep Efficiency = 85%, and Periodic Limb Movement Index = 0/h. The Multiple Sleep Latency Test showed a Mean Sleep Latency in 5 naps = 7 min and Sleep-onset REMs = 3, meeting criteria for narcolepsy. Anti-streptolysin O was less than 200 IU/mL. Guanfacine was switched to nights to reduce daytime sleepiness. Amphetamine-dextroamphetamine was started at 5 mg BID due to palpitations and slowly increased to 20 mg extended release in the morning and 10 mg immediate release in the afternoon. Modafinil has also been added, and both sleepiness and tics are under control. Conclusion: This case reminds us that among other sleep related problems, narcolepsy can coexist in Tourette syndrome. It's interesting that both conditions share an impaired hypothalamus-hypophysis axis but are not commonly linked together. Management is a concern as stimulants can cause tics. We consider medically appropriate to assess and study their sleep problems and treating with stimulants when necessary to improve quality of life.