一例纵向病例报告：重叠睡眠-觉醒表型中的诊断复杂性

文献信息

中文摘要

背景： 单一患者中多种原发性睡眠障碍共存并不常见，并带来显著的诊断和治疗挑战。方法：我们报告一名45岁女性，患有重度混合性睡眠呼吸暂停（OSA/CSA）、NREM异态睡眠（夜惊）、睡眠相关进食障碍（SRED）、梦魇障碍（具有类似RBD的行为，但PSG未见REM肌张力缺失），以及一种中枢性嗜睡表型，该表型在PAP优化后改善甚微，并伴有睡眠-觉醒时相延迟障碍。结果：症状始于二十多年前，包括暴力性梦境演绎行为、醒后幻觉、睡眠惰性以及慢性日间过度嗜睡（EDS）。治疗需要多模式治疗。气道正压治疗成功治疗了睡眠呼吸障碍，而pitolisant和solriamfetol对日间嗜睡产生了最持久的改善。褪黑素联合氯硝西泮共同降低了异态睡眠的频率和严重程度。其他几种药物（包括哌唑嗪、羟丁酸钠、帕罗西汀和莫达非尼）曾被试用，但因获益有限或不良反应而停用。值得注意的是，针对肥胖的GLP-1受体激动剂（GLP-1 RA）治疗后出现了显著体重减轻，并与SRED缓解同时发生。由于这同时伴有睡眠稳定性改善、PAP依从性提高、行为适应和药物调整，因此不能推断因果关系。结论：这一观察可能为进一步研究睡眠相关进食行为中的代谢和肠促胰岛素相关通路提供依据。总体而言，本病例凸显了重叠睡眠-觉醒障碍的复杂性、个体化药物排序的必要性，以及GLP-1激动剂在SRED中潜在的新兴作用。

英文摘要

The coexistence of multiple primary sleep disorders in a single patient is uncommon and poses significant diagnostic and therapeutic challenges. We report a 45-year-old woman with severe mixed sleep apnea (OSA/CSA), NREM parasomnia (night terrors), sleep-related eating disorder (SRED), nightmare disorder (with RBD like behavior but no REM atonia on PSG), and central hypersomnolence phenotype minimally affected with PAP optimization and delayed sleep-wake phase disorder. Symptoms began more than two decades earlier and included violent dream-enactment behaviors, hypnopompic hallucinations, sleep inertia, and chronic excessive daytime sleepiness (EDS). Treatment required multi-modal therapy. Positive airway pressure therapy successfully treated sleep disordered breathing while pitolisant and solriamfetol produced the most durable improvement in daytime sleepiness. Together melatonin plus clonazepam reduced parasomnia frequency and severity. Several other agents (including prazosin, sodium oxybate, paroxetine, and modafinil) were tried and discontinued for limited benefit or adverse effects. Notably, GLP-1 receptor agonist (GLP-1 RA) therapy for obesity was followed by a substantial weight loss and coincided with resolution of SRED. Because this occurred alongside improved sleep stability, PAP adherence, behavioral adaptation, and medication changes, causality cannot be inferred. The observation may justify further study of metabolic and incretin-related pathways in sleep-related eating behaviors. Overall, this case highlights the complexity of overlapping sleep-wake disorders, the need for individualized pharmacologic sequencing, and a potential emerging role for GLP-1 agonists in SRED.