Kleine-Levin syndrome: clues to aetiology

Acute encephalitis induced Kleine-Levin syndrome with episodic vertical gaze dysfunction during hypersomnia episodes

Kleine-Levin syndrome (KLS) is a rare, recurring sleep disorder that easily ignored. Episodic upward-gaze palsy is an uncommon manifestation observed in patients of KLS, which further complicates this disorder. Although peripheral microbial infection have been recognized as most common triggers for KLS, the underlying pathophysiology of this disorder remains unclear. We reported a unique case of KLS elicited by acute encephalitis, which was confirmed by pleocytosis of cerebrospinal fluid at the early stage. The cerebrospinal fluid returned to normal over time while the attacks continued to recur frequently. Episodic upward-gaze palsy was observed during attacks and clinical symptoms were exacerbated following a subsequent COVID-19 infection. This report presents a classic KLS case with distinctive characteristics, which should facilitate more accurate and earlier diagnosis for clinicians. Furthermore, it provides a new perspective for understanding the pathogenesis of this rare disease.

CITATION

Lv H, Long X, Lv Y, Zhou J. Acute encephalitis induced Kleine-Levin syndrome with episodic vertical gaze dysfunction during hypersomnia episodes. J Clin Sleep Med. 2024;20(9):1555-1556.

[Kleine-Levin syndrome]

Kleine-Levin syndrome (KLS) is manifested by periodic hypersomnolence with an increased appetite and psychopathological symptoms (psychomotor agitation, hallucinations, hypersexuality). The duration of the attack ranges from several days to several weeks. A forced awakening can provoke severe aggressive behavior. The disease occurs for an unknown reason, mainly in adolescence and mostly affects males. Lack of awareness among doctors about the disease leads to an incorrect diagnosis, often of a psychopathological disorder. This article presents modern data on the causes, clinical symptoms, diagnostic methods of KLS and provides a case of a 18 year-old man, whose disease manifested at the age of 16 years.

Psychosis Caused by a Somatic Condition: How to Make the Diagnosis? A Systematic Literature Review

BACKGROUND

First episode of psychosis (FEP) is a clinical condition that usually occurs during adolescence or early adulthood and is often a sign of a future psychiatric disease. However, these symptoms are not specific, and psychosis can be caused by a physical disease in at least 5% of cases. Timely detection of these diseases, the first signs of which may appear in childhood, is of particular importance, as a curable treatment exists in most cases. However, there is no consensus in academic societies to offer recommendations for a comprehensive medical assessment to eliminate somatic causes.

METHODS

We conducted a systematic literature search using a two-fold research strategy to: (1) identify physical diseases that can be differentially diagnosed for psychosis; and (2) determine the paraclinical exams allowing us to exclude these pathologies.

RESULTS

We identified 85 articles describing the autoimmune, metabolic, neurologic, infectious, and genetic differential diagnoses of psychosis. Clinical presentations are described, and a complete list of laboratory and imaging features required to identify and confirm these diseases is provided.

CONCLUSION

This systematic review shows that most differential diagnoses of psychosis should be considered in the case of a FEP and could be identified by providing a systematic checkup with a laboratory test that includes ammonemia, antinuclear and anti-NMDA antibodies, and HIV testing; brain magnetic resonance imaging and lumbar puncture should be considered according to the clinical presentation. Genetic research could be of interest to patients presenting with physical or developmental symptoms associated with psychiatric manifestations.

An Update on Kleine-Levin Syndrome

Purpose of Review

Kleine-Levin syndrome (KLS) is a rare relapsing-remitting sleep disorder distinguished by recurrent periods of severe hypersomnia accompanied by cognitive, mood, and behavioral changes. This review focuses mainly on the most recent developments and articles concerning this illness in the preceding five years while attempting to provide a basic overview of KLS.

Recent Findings

Genetic links were reported in some patients with KLS, like variation in TRANK1 in a worldwide case-control genome-wide association in patients with KLS, in addition to several uncommon variations in the LMOD3 gene, some of which are likely to be pathogenic, discovered by linkage analysis and exome sequencing in a sizable Saudi Arabian family with KLS and a European cohort of KLS patients. Additionally, recent data indicate that the amplitude of the circadian active/rest cycles significantly decreased during hypersomnia attacks, but during asymptomatic periods, it did not differ significantly from the controls. Moreover, patients with KLS are at a higher risk of developing emerging psychiatric disorders during follow-up. Recent data also points to possible discoveries of diagnostic-potential dysregulated proteomic patterns in KLS. Finally, new data suggest that functional imaging studies are often abnormal in KLS both during and between episodes.

Summary

KLS is an uncommon, severe, and uniform illness. When it comes to the diagnosis and treatment of KLS, these characteristics offer both opportunities and challenges. Over the past five years, some promising work has appeared in genetics, functional imaging, and biomarker identification; nevertheless, these areas still need more focus to advance the detection and treatment of patients suffering from KLS.

Neuroimaging in the Rare Sleep Disorder of Kleine-Levin Syndrome: A Systematic Review

Kleine-Levin syndrome (KLS) is characterized by episodes of hypersomnia. Additionally, these patients can present with hyperphagia, hypersexuality, abnormal behavior, and cognitive dysfunction. Functional neuroimaging studies such as fMRI-BOLD, Positron Emission Tomography (PET) or SPECT help us understand the neuropathological bases of different disorders. We conducted a systematic review to investigate the neuroimaging features of KLS patients and their clinical correlations. This systematic review was conducted by following the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) and PRISMA protocol reporting guidelines. We aim to investigate the clinical correlation with neuroimaging among patients with KLS. We included only studies written in the English language in the last 20 years, conducted on humans; 10 studies were included. We excluded systematic reviews, metanalysis, and case reports. We found that there are changes in functional imaging studies during the symptomatic and asymptomatic periods as well as in between episodes in patients with K.L.S. The areas most reported as affected were the hypothalamic and thalamic regions, which showed hypoperfusion and, in a few cases, hyperperfusion; areas such as the frontal, parietal, occipital and the prefrontal cortex all showed alterations in cerebral perfusion. These changes in cerebral blood flow and regions vary according to the imaging (SPECT, PET SCAN, or fMRI) and the task performed while imaging was performed. We encountered conflicting data between studies. Hyper insomnia, the main feature of this disease during the symptomatic periods, was associated with decreased thalamic activity. Other features of K.L.S., such as apathy, hypersexuality, and depersonalization, were also correlated with functional imaging changes. There were also findings that correlated with working memory deficits seen in this stage during the asymptomatic periods. Hyperactivity of the thalamus and hypothalamus were the main features shown during the asymptomatic period. Additionally, functional imaging tends to improve with a longer course of the disease, which suggests that K.L.S. patients outgrow the disease. These findings should caution physicians when analyzing and correlating neuroimaging findings with the disease.

Treatment of Kleine-Levin Syndrome With Intranasal Photobiomodulation and Methylene Blue

Kleine-Levin syndrome (KLS) is a rare neuropsychiatric disorder, characterized by recurrent episodes of idiopathic hypersomnia, and cognitive and behavioral abnormalities, such as memory loss and child-like language. There is no definitive etiology for KLS; however, there are hypotheses of genetic predisposition, autoimmune mechanisms, and abnormal thalamic and hypothalamic functioning. Similarly, there is no definitive treatment for KLS as one method may be beneficial for one patient and not for another. We present a case of KLS in a patient who has no clinical improvement in symptoms with a variety of treatments. The parents of the patient agreed to attempt a trial of intranasal photobiomodulation (i-PBM) with red light, in combination with methylene blue (MB). The patient showed remission of the KLS episode following treatment with no further KLS episodes reported after treatment.

SARS-CoV-2 Infection Causes Relapse of Kleine-Levin Syndrome: Case Report and Review of Literature

Recurrent episodes of hypersomnia, hypersexuality, compulsive eating, behavioral and cognitive disturbances, are the basic clinical features of Kleine-Levin syndrome (KLS). Our case report describes a patient who was diagnosed with KLS at the age of 20. With appropriate therapy, the disease had a satisfactory course until patient had a moderate form of SARS-CoV-2 infection, which led to a significant exacerbation of all symptoms. SARS-CoV-2 virus can cause almost any neurological disease, and relapse of KLS is another evidence of neurotropicity of the virus.

Kleine-Levin syndrome related to pregnancy: a case report

Kleine-Levin syndrome (KLS) is a rare disorder of recurrent hypersomnolence. The pathophysiology continues to be poorly understood. Autoimmunity, genetic polymorphisms, dysfunction of the hypothalamic axis, and abnormalities in functional imaging have been proposed. Several triggers have been described, including infection, toxins, head trauma, sleep deprivation, lactation, and menses. We present the first case report in the medical literature of KLS triggered by pregnancy and the first KLS from Armenia. Our patient has a pattern of mostly pregnancy-related episodes of several day sleepiness occurring monthly. This case adds to the published literature as we present a new association and explore the pathophysiology of KLS.