Apparent resolution of hypersomnia episodes in two patients with Kleine-Levin syndrome following treatment with the melatonin receptor agonist ramelteon

Kleine-Levin syndrome (KLS) is a rare disorder characterized by episodic bouts of severe hypersomnia associated with cognitive and behavioral abnormalities and normal alertness and functioning in between episodes. The pathophysiology is unclear but may involve neurotransmitter abnormalities, hypothalamic/thalamic dysfunction, viral/autoimmune etiology, or circadian abnormalities. No single treatment has been shown to be reliably efficacious; lithium has demonstrated the most consistent efficacy, although many do not respond and its use is limited by side effects. Due to the evidence of circadian involvement, we hypothesized that strengthening circadian signals may ameliorate symptoms. Ramelteon is a potent melatonin receptor agonist. In this report, two patients with KLS are described with apparent resolution of hypersomnia episodes following ramelteon initiation.

CITATION

Dominguez D, Rudock R, Tomko S, Pathak S, Mignot E, Licis A. Apparent resolution of hypersomnia episodes in two patients with Kleine-Levin syndrome following treatment with the melatonin receptor agonist ramelteon. J Clin Sleep Med. 2024;20(4):657-662.

Idiopathic Hypersomnia and Kleine-Levin Syndrome: Primary Disorders of Hypersomnolence Beyond Narcolepsy

Daytime sleepiness is common amongst children and adolescents. Inadequate sleep duration, inappropriate school start times, and the delay in sleep phase of adolescence may all contribute. Nocturnal sleep disruption due to sleep disorders such as obstructive sleep apnea or restless legs syndrome/periodic limb movement disorder may also lead to daytime sleepiness. Profound sleepiness however, when occurring in the setting of adequate sleep duration, is rare amongst children and adolescents and may prompt consideration of a central disorder of hypersomnolence (CDH). Narcolepsy is the archetypal and most studied form of CDH and a detailed review of the presentation, evaluation, treatment of narcolepsy is included separately in this edition of Seminars in Pediatric Neurology. In addition to narcolepsy, 2 other forms of primary CDH exist, idiopathic hypersomnia (IH) and Kleine-Levin syndrome (KLS). Onset of IH and KLS occurs most frequently during the pediatric age range and presentation may include signs of encephalopathy in addition to hypersomnolence. As such, they are of particular relevance to pediatric neurology and associated fields. Unfortunately, when compared to narcolepsy little is known about IH and KLS, at both the physiologic and clinical level. This review will focus on the presentation, evaluation, and management of idiopathic hypersomnia and Kleine-Levin syndrome in the pediatric population.

Can Quantitative Electroencephalography and Functional Near-Infrared Spectroscopy be a Good Guide in Kleine-Levin Syndrome?

There is scarce literature on functional neuroimaging data in Kleine-Levin syndrome. The current case report presents the electrical and metabolic status of cortical activity utilizing functional near-infrared spectroscopy (fNIRS) and quantitative electroencephalography (qEEG) before and after treatment of symptomatic phase of illness with modafinil.

Pharmacological treatment for Kleine-Levin syndrome

BACKGROUND

This is an updated version of the original Cochrane review, published in 2009, Issue 2.Kleine-Levin syndrome (KLS) is a rare disorder that mainly affects adolescent men. It is characterised by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behaviour, such as hypersexuality, and signs of dysautonomia.In 1990, the diagnostic criteria for Kleine-Levin syndrome were modified in the International Classification of Sleep Disorders, where KLS was defined as a syndrome comprised of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behaviour. According to the International Classification of Sleepiness Disorders, 3rd version (ICSD-3), revised in 2014, the Kleine-Levin syndrome is a disorder characterized by recurrent episodes of hypersomnia that last from two days to four weeks, with at least annual recurrence, and hyperphagia (rapid consumption of a large amount of food), usually with onset in early adolescence in males but occasionally in later life and in women. A monosymptomatic form of the disorder with hypersomnia only can occur without binge eating or hypersexuality.The cause of Kleine-Levin syndrome remains unknown, and several treatment strategies have been used. Some medications have been reported to provide benefit in the treatment of patients with KLS, but because of the rarity of the condition, no long-term follow-up therapies have yet been described.

OBJECTIVES

This review aimed to evaluate:1. whether pharmacological treatment for Kleine Levin syndrome was effective and safe.2. which drug or category of drugs was effective and safe.

SEARCH METHODS

For the latest update, we searched the following sources: the Cochrane Epilepsy Group Specialized Register (7 April 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online CRSO (7 April 2016); MEDLINE (1946 to April 2016); LILACS (7 April 2016); ClinicalTrials.gov (7 April 2016); WHO International Clinical Trials Registry Platform ICTRP (7 April 2016); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-randomised controlled trials looking at pharmacological interventions for Kleine-Levin syndrome were eligible. We had planned to include both parallel-group and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors (MMO and CC) had planned to extract the data reported in the original articles.

MAIN RESULTS

No studies met the inclusion criteria for this systematic review.

AUTHORS' CONCLUSIONS

Therapeutic trials of pharmacological treatment for Kleine-Levin syndrome with a double-blind, placebo-controlled design are needed.

Pharmacological treatment for Kleine-Levin syndrome

BACKGROUND

This is an updated version of the original Cochrane review, published in Issue 2, 2009.Kleine-Levin syndrome (KLS) is a rare disorder that mainly affects adolescent men. It is characterised by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behavior such as hypersexuality and signs of dysautonomia.In 1990 the diagnostic criteria for Kleine-Levin syndrome were modified in the International Classification of Sleep Disorders, where KLS was defined as a syndrome composed of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behavior.The cause of Kleine-Levin syndrome remains unknown, and several treatment strategies have been used. Some medications have been reported to provide benefit in the treatment of patients with KLS, but because of the rarity of the condition, no long-term follow-up therapies have yet been described.

OBJECTIVES

This review aimed to evaluate:1. whether pharmacological treatment for Kleine Levin syndrome is effective and safe.2. which drug or category of drugs is effective and safe.

SEARCH METHODS

We obtained relevant trials from the following sources: the Cochrane Epilepsy Group Specialized Register (2 May 2013); the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, The Cochrane Library, April 2013); MEDLINE (1946 to 2 May 2013); SCOPUS (2 May 2013); LILACS (2 May 2013); ClinicalTrials.gov (2 May 2013); WHO International Clinical Trials Registry Platform ICTRP (2 May 2013); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-randomised controlled trials looking at pharmacological interventions for Kleine-Levin syndrome were selected. We included both parallel-group and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors (MMO and CC) extracted the data reported in the original articles.

MAIN RESULTS

No studies met the inclusion criteria for this systematic review.

AUTHORS' CONCLUSIONS

Therapeutic trials of pharmacological treatment for Kleine-Levin syndrome with a double-blind, placebo-controlled design are needed.

[The Kleine-Levin syndrome and the treatment with methylphenidate]

A 17-year-old man was referred to the Med-Psych-Unit because of recurrent episodes of hypersomnia, megaphagia, hypersexual behaviour and cognitive disturbances. Over the period of three years he suffered more than 10 episodes of hypersomnia each lasting 8 to 16 days. The clinical presentation was suggestive of the Kleine-Levin syndrome. The symptoms disappeared after treatment with methylphenidate, but it was not clear whether this could be attributed to the medication or to the self-limiting character of the illness. The Kleine-Levin syndrome is often clinically not recognised due to the variation in the symptoms and the lack of objective diagnostic examination.

Pharmacological treatment for Kleine-Levin Syndrome

BACKGROUND

Kleine-Levin Syndrome (KLS) is a rare disorder which mainly affects adolescent men. It is characterized by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behavior such as hypersexuality, and signs of dysautonomia.In 1990 the diagnostic criteria for Kleine-Levin Syndrome were modified in the International Classification of Sleep Disorders, where it was defined as a syndrome composed of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behavior.The etiology of Kleine-Levin Syndrome remains unknown and several treatment strategies have been used. Some medications have been reported to provide some benefit for the treatment of Kleine-Levin Syndrome patients, but because of the rarity of the condition no long-term follow-up therapies have yet been described.

OBJECTIVES

This review aimed to evaluate:1. whether pharmacological treatment for Kleine-Levin Syndrome is effective and safe; and 2. which drug or category of drugs is effective and safe.

SEARCH STRATEGY

We obtained relevant trials from the following sources: the Cochrane Epilepsy Group Specialized Register (1 December 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2007); MEDLINE (1966 to December 2007); EMBASE (1980 to December 2007); LILACS (1982 to December 2007); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies.

SELECTION CRITERIA

All randomized controlled trials (RCTs) and quasi-randomized controlled trials looking at pharmacological interventions for Kleine-Levin Syndrome. We included both parallel group and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors (MO and CC) extracted the data reported in the original articles.

MAIN RESULTS

No studies met the inclusion criteria for this systematic review.

AUTHORS' CONCLUSIONS

Therapeutic trials of pharmacological treatment for Kleine-Levin Syndrome, with a double-blind, placebo-controlled design are needed.

Gabapentin for Kleine-Levin syndrome

We describe a 17-year-old girl with Kleine-Levin syndrome (KLS), in which gabapentin was effective for the prevention of attacks. (99)mTc-ECD SPECT revealed hyperperfusion of the thalamus and nucleus accumbens presenting in the symptomatic period, suggesting epilepsy-like neuronal discharge from these structures. Treatment for KLS has not been established, although lithium has been used in limited cases with insignificant efficacy. Here, we report a case of recurrent hypersomnia in which gabapentin was effective for the prevention of attacks. We speculate that the recurrent hypersomnia and behaviour disturbance are related to epilepsy-like neuronal discharge from the thalamus due to dysfunction in GABAnergic receptors.

Sarcoidosis: a rare cause of Kleine-Levine-Critchley syndrome

Hypothalamic sarcoidosis is a rare entity that can alter the hypothalamic-pituitary axis and induce various combinations of endocrine changes. We present a case of neurosarcoidosis with uncommon features of hypersomnolense and hyperphagia. Current strategies to increase awareness and prevention of the harmful effects of obesity require clinicians to be cognizant of potential disorders that produce these features The mechanism, differential diagnosis and therapeutic options of this organic etiology are reviewed.

Kleine-Levin syndrome: interface between neurology and psychiatry

We report the first episode of Kleine-Levin (KLS) syndrome in a 17-year-old male. The illness onset, clinical features, neuropsychological evaluation and polysomnographic recording are described. Typical symptoms hypersomnia, hyperphagia and sexual disinhibition were observed besides behavioral disturbances, polysomnographic and neuropsychological alterations. Behavioral disturbances similar to a manic episode including psychotic symptoms were relevant. The pharmacologic treatment included lithium, methylphenidate and risperidone. The introduction of risperidone aimed the control of psychotic symptoms and the persistent manifestations of hypersexuality after sleepiness control and to the best of our knowledge there are no other reports regarding risperidone use for KLS in the literature.

Kleine-Levin syndrome: a systematic review of 186 cases in the literature

Kleine-Levin syndrome (KLS) is a rare disorder with symptoms that include periodic hypersomnia, cognitive and behavioural disturbances. Large series of patients are lacking. In order to report on various KLS symptoms, identify risk factors and analyse treatment response, we performed a systematic review of 195 articles, written in English and non-English languages, which are available on Medline dating from 1962 to 2004. Doubtful or duplicate cases, case series without individual details and reviews (n = 56 articles) were excluded. In addition, the details of 186 patients from 139 articles were compiled. Primary KLS cases (n = 168) were found mostly in men (68%) and occurred sporadically worldwide. The median age of onset was 15 years (range 4-82 years, 81% during the second decade) and the syndrome lasted 8 years, with seven episodes of 10 days, recurring every 3.5 months (median values) with the disease lasting longer in women and in patients with less frequent episodes during the first year. It was precipitated most frequently by infections (38.2%), head trauma (9%), or alcohol consumption (5.4%). Common symptoms were hypersomnia (100%), cognitive changes (96%, including a specific feeling of derealization), eating disturbances (80%), hypersexuality (43%), compulsions (29%), and depressed mood (48%). In 75 treated patients (213 trials), somnolence decreased using stimulants (mainly amphetamines) in 40% of cases, while neuroleptics and antidepressants were of poor benefit. Only lithium (but not carbamazepine or other antiepileptics) had a higher reported response rate (41%) for stopping relapses when compared to medical abstention (19%). Secondary KLS (n = 18) patients were older and had more frequent and longer episodes, but had clinical symptoms and treatment responses similar to primary cases. In conclusion, KLS is a unique disease which may be more severe in female and secondary cases.

Kleine-Levin syndrome

Kleine-Levin Syndrome (KLS) is a rare disorder of uncertain etiology, characterized by recurring episodes of undue sleepiness lasting for days. We report a case of young female presenting with episodes of undue sleep along with hypersexuality and excessive food intake, who improved significantly on lithium and valproate. KLS should be considered in young patients, who present with episodes of undue somnolence.

The Kleine-Levin syndrome - effects of treatment with lithium -

Kleine-Levin syndrome (KLS) is a rare disorder which affects mainly adolescents. Periods of extreme somnolence alternate with megaphagia, psychomental changes and behavioural symptoms. The cause and pathogenesis of KLS remains unknown. Several treatments have been tried and recently lithium has been proposed for a prophylactic use in single cases. In view of the rarity of KLS, long-term results of lithium therapy have not been described yet. We report the clinical course of five adolescents with KLS who were treated with lithium. All patients showed significant EEG and polysomnographic changes during the episodes and had normal results in the interval. All patients had relapses while being treated with lithium. But episodes of hypersomnia under lithium therapy were shorter and monosymptomatic with lack of behavioural symptoms. Statistical modelling showed that the risk for a relapsing episode under maintenance of lithium drops per months of therapy from 100 % to 93 %, and furthermore that the maintenance of lithium shortens the mean duration of episodes to 19 %. No severe side effects were observed. In conclusion, in KLS with a high frequency of episodes and severe behavioural changes lithium may become a treatment option.

[SPECT-identified hypoperfusion of the left temporomesial structures in a Kleine-Levin syndrome]

A 13-year-old boy developed typical features of Kleine-Levin syndrome. Routine investigations and MRI were normal. SPECT, performed both during an attack and during a symptom-fee period, demonstrated clear hypoperfusion of the left mesiotemporal structures. The possible implications of this finding are discussed.

Kleine-Levin syndrome. Clinical course, polysomnography and multiple sleep latency test. Case report

A case of Kleine-Levin syndrome, with chronic severe periodic hypersomnia is described in a 17-year-old female. The first episode started when she was 15 years old. The episodes were characterized by periodic hypersomnia accompanied by hyperphagia, lasting 5 days, and repeating at 28 to 60 day intervals. The severity of hypersomnia prevented her from attending school activities. Outside the hypersomnia periods, she was asymptomatic. EEG, brain computerized tomography and brain nuclear magnetic resonance were normal; all-night polysomnography, Multiple Sleep Latency Test (MSLT) and Epworth Sleepiness Scale (ESS) were within normal limits. During the period of hypersomnolence, polysomnography showed short sleep latency and short REM latency. MSLT mean sleep latency was 1.8 min; and REM period was present in one subtest; the ESS was markedly elevated.

[Recurrent hypersomnia]

The recurrent hypersomnia is a rare disorder and diagnosed by recurrent episodes of hypersomnia more than 18 hours a day lasting from several days to several weeks. The Kleine-Levin syndrome is a subtype of the recurrent hypersomnia and characterized by excessive eating or hypersexuality. I review the clinical features of recurrent hypersomnia comparing with our own two cases. The slight consciousness disturbance is seemed to cause the hypersomnic state. Several neurophysiological findings also support this hypothesis. Generally, the prognosis of this disorder is good. The psychophysical factor is seemed as a major factor to induce this disorder, therefore to reduce this factor is one of the most important treatment and the lithium carbonate is also useful as a pharmacotherapy. The mechanism of this disorder is still unknown.

Kleine-Levin syndrome: a cause of diagnostic confusion

The case is described of a boy with the Kleine-Levin syndrome in whom prominent behavioural disturbances and the initial absence of a clear cyclical pattern obscured the diagnosis. Treatment with lithium was effective.