Niger J Paed 2014; 41 (4): 386 - 389

CASE REPORT

Eseigbe EE

Diagnostic challenges and

Nuhu FT

Sheikh TL

psychosocial impacts of hypersom-

Oguizu OJ

nia in a Nigerian adolescent: A case

Ezebuiro OGC

report

Eseigbe P

Sanni KA

Baduku TS

DOI:http://dx.doi.org/10.4314/njp.v41i4,19

Accepted: 3rd May 2014

Abstract Hypersomnia, a disorder

intelligence

was

also

normal.

of sleep characterized by exces-

There was no contributory past

Eseigbe EE (

)

sive quantity of sleep and exces-

medical history or demonstrable

Eseigbe P

etiology.

Magnetic

Resonance

Departments of Paediatrics &

sive daytime sleepiness (EDS),

Family Medicine,

could adversely affect health out-

Imaging (MRI) of the brain, Elec-

Ahmadu Bello University Teaching

comes in childhood. To highlight

tro Encephalogram (EEG), assay

Hospital, Shika Zaria, Nigeria

diagnostic challenges and the im-

of serum electrolytes were all nor-

Email: eeeseigbe@yahoo.com

pact of childhood hypersomnia in

mal while screening test for try-

a resource limited setting, a 14

panosomiasis was negative. Poor

Nuhu FT, Sheikh TL, Oguizu OJ

year old Nigerian who presented

level of awareness, high cost of

Sanni KA

with a seven year history of hy-

evaluation and limited facilities for

Federal NeuroPsychiatric Hospital,

persomnia was studied. Screening

diagnosis of sleep disorder were

Kaduna, Nigeria

for sleep disorder using BEARS

the major diagnostic challenges.

Ezebuiro OGC

sleep algorithm and assessment

Depression, poor academic per-

Nigerian Institute for Trypanosomiasis

for

EDS

using

the

Epworth

formance, suicidal ideation and

Research, Kaduna, Nigeria

Sleepiness Scale were both posi-

stigmatization were all associated

tive for EDS. The assessment of

with hypersomnia in the patient.

Baduku TS

sleep hygiene using the Adoles-

Department of Radiology,

cent Sleep Hygiene Scale was

Keywords: Hypersomnia, adoles-

Kaduna State University, Nigeria

normal and the use of Raven’s

cence, depression, sleep disorders,

Progressive Matrices to assess

d iagnostic challenges

Introduction

prevalence of sleep disorders in the Nigerian population

are lacking . However studies on EDS, the cardinal fea-

7

Sleep disorders such as hypersomnias, parasomnias, and

ture of hypersomnia, from Nigeria indicate a prevalence

insomnias could impair development and result in poor

of 53% among children with neurological disorders,

health and social outcomes in childhood . Hypersom-

1,2

44.8% among adults with depression and 17% in a

school population . An EDS prevalence rate of 15%

7-9

nias, characterized by an excessive quantity of sleep and

excessive daytime sleepiness (EDS), is one of the major

has also been reported from a school population in the

categories of sleep disorders identified by the Interna-

United States while worldwide estimates put the preva-

tional Classification of Sleep Disorders (ICSD-2) .

3-5

lence of EDS as ranging four to 30% in adult popula-

tions .

3,6

Sleep disorders in this category include narcolepsy and

its variants, idiopathic hypersomnia with and without

long sleep time, behaviorally induced insufficient sleep

In adolescence the recommended sleep duration is 8.5 to

10.5 hours daily . However self-reported nocturnal

10

syndrome, and recurrent hypersomnia typified by Klein-

Levin syndrome . Also in this category is hypersomnia

4,5

sleep time declines across the adolescent span just as

bed times grow later and rising times earlier . In addi-

10

due to substance abuse and medical conditions, such as

obesity, obstructive sleep apnea, depression, head

tion adolescents have a higher tendency for daytime

trauma and brain tumors .

4,5

sleepiness which is not related to the amount of sleep at

night . Thus incidence of hypersomnia is susceptible to

10

The estimated prevalence rates for the hypersomnias

inappropriate estimation in adolescence. Nevertheless,

include: 0.3% for idiopathic hypersomnia, 0.045% for

hypersomnia has ominous implications for cognitive

narcolepsy and a range of 1-4% for the behaviorally

development with impairment in learning, motivation,

attention span and academic achievement

1,2,11

induced insufficient sleep syndrome . Studies on the

6

. Further-

387

more its incidence in adolescence has been associated

(SMR) staging was Stage 3 (Mid- Adolescence). The

with increased susceptibility to accidents, and depres-

initial screening assessment for sleep using BEARS

sion

3,12

. It could also signify presence of a grave medical

sleep screening algorithm indicated that EDS was the

only affected domain. The Adolescent Sleep Hygiene

13

condition such as a brain tumor . Consequently child-

6

hood hypersomnia demands comprehensive assessment

Scale (ASHS) score was 63% of the maximum score

and indicative of normal sleep hygiene.

14

and management.

The Epworth

Studies and reports on childhood sleep and sleep related

Sleepiness Scale (ESS) score was 19 (Table 1), with

disorders, particularly in an environment like ours with

maximal scores in all sedentary parameters, indicating

EDS

7,15

limited services for sleep disorders, could increase

. The examination of the central nervous system

awareness and facilitate the development and provision

was normal except for the findings of: loss of interest,

of such services . The studies could achieve these

7,8

sad mood, impaired concentration and suicidal ideation

through increasing awareness, and providing data, on

while using the Hospital Anxiety and Depression Scale

(HADS) instrument to assess for depression . His

16

the need to provide diagnostic and therapeutic services

for sleep disorders.

HADS score was 12 which is greater than the cutoff for

depression. Assessment of intelligence using the Ra-

To promote awareness and highlight diagnostic chal-

ven’s Progressive Matrices indicated an average intel-

lenges as well as the impact of sleep disorders in child-

lectual capacity and performance. The Card Agglutina-

hood in our environment we studied a 14 year old who

tion Test for Trypanosomiasis (CATT) was negative.

presented with hypersomnia of unknown etiology. It was

The Electro Encephalo Gram (EEG) and serum electro-

the first of such a case in the first 3000 cases seen at the

lytes and urea assay showed no abnormality. The Mag-

Child and Adolescent Mental Health (CAMH) Unit of

netic Resonance Image (MRI) scan of the brain (Fig 1)

the Federal Neuro Psychiatric Hospital (FNPH) in

showed mild prominence of the sulci which was re-

Kaduna, Northern Nigeria.

ported as a normal variation. In the absence of structural

abnormalities and considering the fact that childhood

Case Report

peaks of gray matter development is followed by a de-

cline in adolescence, the MRI was reviewed as normal

by the authors . Due to lack of facilities for sleep stud-

17

S.J. is a 14 year old male who presented to the CAMH

Unit with a seven year history of excessive sleep during

ies in the CAMH unit and in our region of practice poly-

the day. The informants were the patient and his parents.

somnography and multiple sleep latency test (MSLT)

In the 18 months prior to presentation the duration of his

were not done. Despite subsidization the estimated cost

day time sleep had increased to an average of 45 min-

of the investigations was a hundred thousand naira ($

utes with a frequency of 4 times daily. His sleep at night

625.00) as against the eighty thousand naira ($500) av-

was described as normal lasting an average of eight0

erage monthly income of the family.

hours per night. There was no history of sleep related

Table 1: Patient’s Epworth Sleepiness Scale (ESS)

8,15

hallucination, weakness, snoring or that suggestive of

score

difficulty with breathing while at sleep. The patient was

Activity

Situation Chance

not on any routine medication nor was there a history of

of Dozing (Score

substance abuse. There was no past history of trauma to

0-3)*

the head, that which was suggestive of meningitis or

1

Sitting and reading

2

encephalitis. The patient’s EDS was initially attributed

2

Watching TV

2

to laziness by parents and school teachers. However

3

Sitting, inactive in a public place (e.g. a

3

progression in the duration and frequency EDS necessi-

theatre or a meeting)

4

As a passenger in a car for an hour without

3

tated several visits to the family clinic and other secon-

a break

dary health facilities where parents were reassured the

5

Lying down to rest in the afternoon when

3

patient would overcome his sleepiness. His growth is

circumstances permit

said to be normal and comparable to that of his siblings

6

Sitting and talking to someone

1

7

Sitting quietly after a lunch without alcohol

3

and peers. His academic performance was described as

8

In a car, while stopped for a few minutes in

2

initially good but had gradually deteriorated in the past

the traffic

three years. This culminated in his being asked to repeat

Total

19

his last class grade in school. The patient complained

about taunts from his peers in the school concerning his

*Scoring Scale

sleepiness. He was also unhappy about his uncontrolla-

0 = would never doze, 1 = slight chance of dozing, 2 = moder-

ble propensity to sleep. The patient is the second of

ate chance of dozing

3 = high chance of dozing

three children in a monogamous setting. His father is a

50 year old self-employed engineer and mother, a 43

year old unemployed university graduate. His siblings

were said to be doing well academically and there no

family history of hypersomnia or any mental disorder.

At presentation he was well kempt, not pale, had no cer-

vical lymphadenopathy. His Body Mass Index (BMI)

A

B

C

was 22.1kg/m (Normal) while his Sexual Maturity Rate

2

Fig 1. (A) Axial cut showing normal cerebral mantle and ventricles. (B) Sagittal and

(C) Coronal cuts showing mildly prominent sulci.

388

In view of the indeterminate findings and duration of

present with depressive symptoms. Depression is often

debated as etiological or an outcome in hypersomnia.

3

sleep at night ( less than 10 hours) a clinical diagnosis of

hypersomnia of unknown etiology (idiopathic hyper-

Depressive symptoms have been noted in 15-25% of

patients with idiopathic hypersomnia. In our patient

3

somnia) without long sleep time, with complicating de-

pression, was made. The patient was commenced on

depression was considered as an outcome because of the

psychotherapy, oral amitriptyline (50mg b.i.d.) for de-

development of depressive symptoms after onset, and

pression and given clinic appointments to monitor his

with increasing severity, of EDS. The implication of

management. Depression and the confounding expres-

depression is particularly worrisome in the adolescent as

sion of suicidal ideation necessitated our prescription of

it reduces adolescent productivity, increases the risk of

an anti-depressant. The prescription of other effective

substance abuse and suicidality, and that of involvement

with the juvenile justice system.

20

anti-depressant drug such as fluoxetine, of the selective

serotonin re uptake inhibitors' class, was not considered

because of the history of suicidal ideation in the patient

The management of hypersomnia due to medical condi-

which itself is a side effect of the drug. Furthermore, the

tions focuses on the treatment of the etiological factors.

effectiveness of the use of a wake-promoting drug such

However there is currently no cure for idiopathic hyper-

somnia.

18,19

as modanifil or that of a stimulant such as methyl pheni-

Its contemporary scope of management in-

date that has been demonstrated to provide variable suc-

clude the use of wake promoting medication such as

cesses in the treatment of idiopathic hypersomnia could

modanifil and stimulants such as methyl phenidateeven

not be ascertained because the drugs are not available in

though they have been reported not to be very effective

our practice.

3,18

He was introduced to a series of absorb-

in the management of idiopathic hypersomnia.

18,19

Be-

ing leisure time activities while counseling sessions

havioral approaches and sleep hygiene techniques have

were organized for him and other members of his fam-

also been employed with overall little beneficial ef-

fects. Spontaneous improvement in symptoms has been

19

ily. Informative interactive sessions were also under-

taken with his class teachers and school authority.

reported in a minority among a cohort of patients with

idiopathic hypersomnia.

18

The relative high cost of accessing health care for hyper-

Discussion

somnia in this study highlights the challenge that could

confront accessing health care for uncommon or com-

Hypersomnia of unknown etiology in this Nigerian ado-

plex health disorders in our environment with resultant

lescent was characterized by a seven year delay in diag-

defaults in management. This is even more remarkable

nosis, high cost of investigations and limited facilities

in settings where there are no supportive or limited

for diagnosis of sleep disorders. Its impact included a

health care funds to access. Additionally, as it is with

most chronic disorders,

21

poor academic performance, depression, felt stigma,

hypersomnia could impact

suicidal ideation and increased family expenditure. Psy-

negatively on the physical, economic and psychosocial

cho social implications of hypersomnia have been re-

wellbeing of other family members.

ported from other regions of the world as well as the

Lack of facilities for conducting sleep studies and man-

dearth of facilities for sleep studies in the country.

1-3,7,8

agement of sleep disorders were limitations in the study.

It took seven years and a significant progressive deterio-

The weakness in the health system’s ability to provide

ration in academic in performance before a concerted

readily accessible and available services for sleep disor-

effort was undertaken by his caregivers to unravel the

ders, as observed in this study and other studies from the

country,

7,8

disorder. It underscores the poor degree of awareness

is probably influenced by the health systems

about sleep disorders in the patient’s immediate environ-

need to address other more common childhood disor-

ment. The perception of EDS as a form of laziness and

ders. Improving the health system’s capacity to manage

that he will outgrow it further buttresses the assertion.

sleep disorder would enhance awareness, promote favor-

able outcomes and strengthen health care delivery in

The presentation of hypersomnia in adolescence could

general.

have significant implications. It could reflect a past

1-4

history of head injury, encephalitis or, indicate the pres-

Hypersomnia was associated with diagnostic challenges

ence of substance abuse. It could also signify the pres-

4

and detrimental psycho social outcomes in this study.

ence of a potentially ominous condition such as a brain

Improved awareness and a better outcome with hyper-

tumor. Furthermore, it could be indicative of more spe-

7

somnia, and other sleep disorders, could be achieved

cific sleep disorders such as narcolepsy, which is addi-

through communal enlightenment campaigns, instruc-

tionally characterized by cataplexy and hallucinations,

tional school health initiatives, provision of diagnostic

and Klein-Levin syndrome which has megaphagia and

facilities in the health system, training of teachers and

increased sexuality as complimenting features.

18,19

These

child health practitioners in the management of sleep

enumerated features that have been associated with hy-

disorders.

persomnia were absent in our patient. However he did

389

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