[Clinical characteristics and morphology of Pickwickian syndrome]

Clinical and morphological evidence obtained for 23 patients with Pickwickian syndrome has been analysed. 18 patients had no other symptoms, 12 patients died of the disease. Standard signs of the syndrome (drowsiness, respiratory distress, diffuse cyanosis, etc.) were not universal, whereas mixed-type respiratory disorders occurred in all the patients as well as right heart hypertrophy, sclerosis and hyalinosis of the lesser circulatory bed found morphologically and histologically.

[A case of Pickwickian syndrome treated by implantation of a cardiac permanent pacemaker]

A 41-year-old male was admitted to our hospital with congestive heart failure and bronchopneumonia. During hospitalization extreme sinus bradycardia, sinus arrest up to 6.2 seconds and high grade AV block were observed to occur simultaneously with apneic episodes of ECG monitoring. After that, a diagnosis of Pickwickian syndrome was made in this obese patient. In spite of weight reduction, change of sleep position and acetazolamide administration, obstructive sleep apnea and severe bradyarrhythmias were not improve. These severe bradyarrhythmias and ventricular tachyarrhythmias may be one cause of the not infrequent sudden deaths in patients with this Pickwickian syndrome. In addition to the tracheostomy, we propose that implantation of a cardiac permanent pacemaker should be selected for the bradyarrhythmias in association with the Pickwickian syndrome.

Sleeping beauty: a case of pickwickian syndrome

The patient arriving at the emergency department with somnolence must be evaluated quickly, efficiently, and with a definite goal in mind. Head and neck trauma should always be suspected and protective steps taken in the unconscious patient. The coma mnemonic, AEIOU TIPS, (alcohol, epilepsy, insulin, overdose, uremia, trauma, infection, psychiatric, stroke) provides an excellent memory tool for the evaluation of decreased level of consciousness in the emergency setting. Interventions that provide diagnostic and therapeutic results (naloxone and 50% dextrose) should be initiated immediately while blood samples are drawn for pretreatment documentation. Each of the possible causes of lethargy or somnolence needs to be evaluated with the understanding that a multitude of factors may be present in the patient whose condition precludes a thorough history; the depressed diabetic may have taken an overdose of medications in addition to his insulin. Social preconceptions may also effect the outcome. The intoxicated patient described herein was allowed to "sleep it off" in the emergency department under the watchful eyes (and ears) of a nursing staff who faithfully recorded vital signs and pupil reactivity as the patient's blood gas values deteriorated.

[Neurophysiologic studies in Pickwickian syndrome]

In 11 patients clinically diagnosed as Pickwickian syndrome the results of daytime and night polysomnogramm were compared. The daytime recording was very efficient in identifying apnoea and correlating various types of apnoea to different sleep stages. In polysomnogramms of night sleep we found, as did Lugaresi, a reduction of sleep stages III and IV, and a slight increase of sleep stages I and II. Patients without apnea in daytime sleep also showed a normal apnea index in night sleep. The BAEP's especially the pontomesencephalic components were pathological in six patients (55%). This might be due to a primary lesion or to hypoxic damage of the brainstem.

[Contribution of nocturnal polygraphy to the diagnosis of Pickwickian syndrome. 10 cases]

The authors studied a series of 10 obese patients with respiratory failure referred for treatment because of sleep disorders and diurnal, sometimes uncontrollable, episodes of somnolence. 8 parameters were recorded in the polygraphic study performed during a night of hospitalization: electroencephalogram, electrocardiogram, electro-oculogram, chin electromyogram, thoracic movements, and nasal and buccal air flows. SaO2 and transcutaneous PO2 were recorded simultaneously. A sleep apnea syndrome was diagnosed in 6 of the 10 patients, whose apnea index was markedly above the limit of 5 apneas per hour. The apnea index was below 5 in the other 4 patients. Most patients with sleep apnea syndrome suffer from obstructive apneas of varying duration taking up as much as 48% of total sleep time. The cardiorespiratory effects of these events are apparent, with a drop in PO2 and SaO2 and a decrease in heart rate at the end of apnea. Polygraphic studies seem useful in the diagnosis of the pickwickian syndrome. They allow the type of apnea and its effects to be specified and thus guide treatment.

[Differential diagnostic problems and polygraphic studies in a case of Pickwickian syndrome]

The case report of a male patient with the Pickwickian syndrome is presented. The results of the relevant neurophysiological examinations (polygraphic registration of EEG, electrocardiogram, respiration, thorax excursions, submental and intercostal electromyogram, electrooculogram) give an insight into the pathomechanisms and enable the differential diagnosis to be made between this condition and narcolepsy and also the Kleine-Levin syndrome; respiratory investigations (spirometry, hypercapnic ventilatory response: mouth occlusion pressure) make it possible to differentiate between the Pickwickian and Ondine's curse syndrome. The therapeutic management is discussed.

[Hypersomnias. Myth and reality. Global approach]

Given the progress in neurophysiology the authors are attempting to define the concept of hypersomnia. In the first part they review the principal clinical tables in which this symptom finds its place in adults and children. The second part treats a study of psychogenic hypersomnia in light of the psychoanalytical theory concluding with what seems to be the apparent relationship between the body's signs and the significant.

[Hypersomnia with periodic apneas (author's transl)]

Patients suffering from Pickwickian syndrome or primary hypoventilation syndrome present apneas of a predominantly obstructive type which follow one another without interruptions throughout the duration of sleep. It is not possible to ascribe the somnolence of these patients to carbonarcosis, because in most cases Pa CO2, though high during sleep, presents normal values or slightly higher than normal values during wakefulness. Obstructive apneas are the cause of this syndrome: the elimination of obstructive apneas by means of tracheostomy leads to a complete clinical recovery. Before they began to suffer from hypersomnia, all these patients had been snoring heavily for many years. Snoring is therefore a fixed stage in the evolution of this disease. The fact that the overall clinical and polygraphic characteristics of these syndromes are identical suggests that they all constitute a single nosographic entity, which we have called "hypersomnia with periodic apneas".

Sleep apnea syndrome. Practical diagnostic method

We report a method of evaluating sleep apnea by equipment available and easily assembled in the majority of community hospitals. Two cases fully studied by this method are presented.

Hypersomnia with periodic breathing (an acromegalic Pickwickian)

The syndromes of Pickwickian, Ondine's curse, and primary alveolar hypoventilation are respiratory disorders manifesting increased sleepiness and irregular respiratory rhythms. These disorders are currently grouped as hypersomnia with periodic breathing (HPB). Polygraphic techniques have lead to a reasonable hypothesis as to the pathophysiology of the multiple variants of HPB. Discernible causes of HPB have been attributed to both central and peripheral factors. Peripheral factors encompass those conditions relating to upper airway obstruction. An acromegalic person suffering the HPB syndrome secondary to laryngeal stenosis is described.