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CASE REPORT
Narcolepsy after A/H1N1 vaccination
Mirian Fabiola Studart Gurgel MendesI, Dirceu de Campos Valladares NetoII, Rosângela Aparecida de AzevedoIII, Paulo CaramelliIV,
Corresponding author
caramelli@ufmg.br

Tel.: 55 31 3409-9746
I Hospital Madre Teresa, Belo Horizonte/MG, Brazil.
II Fundação Nacional do Sono/Clínica do Sono, Nova Lima/MG, Brazil
III Secretaria de Estado da Saúde, Sistema de Informações de Efeitos Adversos pós-vacinais, Coordenação de Imunizações, Belo Horizonte/MG, Brazil
IV Faculdade de Medicina da Universidade Federal de Minas Gerais, Departamento de Clínica Médica, Belo Horizonte/MG, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Narcolepsy is defined as a pentad of symptoms that include excessive daytime sleepiness&#44; disturbed nocturnal sleep&#44; sleep paralysis&#44; cataplexy&#44; and hypnagogic or hypnopompic hallucinations<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#46; The cause of narcolepsy is still unknown&#44; although it has been associated with a combination of genetic and environmental factors&#59; the prevalence is approximately 0&#46;04&#37;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#46; The peak age of onset is the second decade of life&#44; and onset after age 55 or prior to age 10 is rare&#46; Not every symptom is present in all patients&#44; and the severity is also variable<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">Hypocretin&#44; a neuropeptide of hypothalamic origin&#44; has been involved in the pathogenesis of narcolepsy&#46; The CSF hypocretin-1 levels are very low or even undetectable in most narcoleptic patients with cataplexy&#46; The HLA-DQB1&#8727;0602 allele&#44; which is involved in the control of the hypocretin receptor&#44; is also present in 88&#37; to 98&#37; of such patients<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">The association between narcolepsy and vaccination against the 2009 pandemic influenza A &#40;H1N1&#41; virus was initially suggested in 2010 in Finland and Sweden&#44; leading to the suspension of vaccination in these countries<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#46; Additional cases were subsequently reported<a class="elsevierStyleCrossRefs" href="#bib4">4-5</a>&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Herein&#44; we describe a patient with narcolepsy with cataplexy syndrome after A&#47;H1N1 vaccination in Brazil and discuss the potential causes and treatment&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE REPORT</span><p id="para50" class="elsevierStylePara elsevierViewall">A 19-year-old woman&#44; first observed in May 2010&#44; 40 days after being vaccinated against the 2009 pandemic influenza A &#40;H1N1&#41; virus &#40;Arepanrix&#8482; - Lot A80CA254A&#41;&#44; complained of acute and intense headache&#46; Physical examination and general blood tests were unremarkable&#46; A few days later&#44; she presented with uncontrollable sleep attacks&#44; a sensation of &#8220;dreaming with open eyes&#8221;&#44; nightmares&#44; and a poor quality of sleep&#46; An electroencephalogram&#44; an MRI of the skull&#44; and thyroid laboratory test results were all found to be normal&#46; She gained 9 kg &#40;19&#46;8 lbs&#41; in two months&#46; In September&#44; she presented with cataplexy&#44; hypophonia&#44; and weakness in all limbs without falls&#46; In February 2011&#44; she experienced an episode of sleep paralysis but no hypnagogic hallucinations&#46; The results of a neurological examination were normal&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">The patient scored 19 points on the Epworth Somnolence Scale&#46; Polysomnography disclosed a sleep efficiency of 81&#46;8&#37; and a sleep latency of three minutes&#46; She did not display apnea&#47;hypopnea but had a Respiratory Effort Related Arousal &#40;RERA&#41; index of 72&#44; which was normalized with nasal Continuous Positive Airway Pressure &#40;CPAP&#41; &#40;8 cm H2O&#41;&#46; She subsequently presented with very stable sleep&#46; The multiple sleep latency test&#44; performed one week after the introduction of nasal CPAP to avoid false-positive results&#44; revealed sleep latencies between 1 and 6&#46;5 minutes&#44; and three sleep onset rapid eye movement periods &#40;SOREMPs&#41; lasting from 8 to 12 minutes&#46; Notably&#44; the patient carries the HLA-DQB1&#8727; 06&#58;02 allele&#46; The CSF hypocretin level could not be determined because the test was not available in the state of Minas Gerais&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">Based on the overall clinical findings and on the results from the ancillary tests&#44; a diagnosis of narcolepsy was made<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#46; Appropriate communication to the public service for pharmacological vigilance and to the company responsible for the production of the vaccine were first undertaken on September 30&#44; 2010&#46; The patient was treated with modafinil &#40;200 mg&#47;day&#41; for hypersomnolence and venlafaxine &#40;37&#46;5 mg&#47;day&#41; for cataplexy&#46; This approach to treatment achieved an excellent clinical response&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para80" class="elsevierStylePara elsevierViewall">There is some evidence that narcolepsy is an autoimmune disorder or involves an infectious agent with participation of the immune system<a class="elsevierStyleCrossRefs" href="#bib7">7-8</a>&#46; Cases of narcolepsy after 2009 pandemic influenza A &#40;H1N1&#41; virus vaccination have been described in Sweden&#44; Finland&#44; Canada&#44; France&#44; and the United States<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#46; The diagnosis was defined by the association of hypersomnolence&#44; cataplexy&#44; presence of the HLA DQB1&#8727;0602 allele&#44; a positive multiple sleep latency test for narcolepsy&#44; and low CSF hypocretin levels&#46; By January 2011&#44; 162 patients vaccinated with Arepanrix&#8482; presenting narcolepsy were reported to GlaxoSmithKline<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Reported cases experienced an onset of symptoms ranging from two days to five months &#40;usually two to eight weeks&#41; after vaccination&#44; intense and unusual hypersomnolence&#44; cataplexy&#44; rapid weight gain&#44; and atypical age for narcolepsy&#46; Most cases received vaccines with ASO3 as an adjuvant &#40;Arepanrix&#8482; and Arepanrix&#8482;&#41;&#44; which are associated with stronger immune responses&#44; and not with Panenza&#8482;&#46; An association between narcolepsy&#44; streptococcal infection and A&#47;H1N1 influenza has also been reported<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#46; Putative mechanisms include trigger of a specific immune response to A&#47;H1N1 followed by molecular mimicry or generalized stimulation of the immune system<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#46; The WHO Independent Global Advisory Committee on Vaccine Safety reported no increased risk of narcolepsy associated with the use of any vaccine in the past<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">The presented case occurred after A&#47;H1N1 vaccination with ASO3&#46; The clinical and neurophysiologic features&#44; plus the HLA genotype&#44; even without CSF hypocretin data&#44; fulfill the diagnosis of narcolepsy&#44; according to the recently published Brazilian guidelines<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#46; Such guidelines state that the determination of CSF hypocretin levels is mandatory only in cases of narcolepsy without cataplexy or in patients with negative multiple sleep latency test results&#46; Considering the temporal association between the vaccination and the emergence of the clinical symptoms&#44; there may be a link with the vaccine&#46; Interestingly&#44; however&#44; our patient presented with cataplexy &#40;hypocretin receptor-2 knockout&#41; without fragmented sleep patterns &#40;no hypocretin receptor-1 knockout&#41;&#44; suggesting a link between receptor-2 and susceptibility to this vaccine&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">Post-vaccine narcolepsy may be less rare than previously thought&#46; Diagnosis in the early stages would allow for the use of certain treatment options such as immunosuppressors that may be able to arrest or at least delay hypocretin cell loss<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#44; and&#47;or the use of the usual stimulant and antidepressant drugs&#46;</p></span></span>"
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es en pt

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