Rapid Eye Movement (REM)-Predominant Obstructive Sleep Apnea (OSA) Coexisting With and Initially Obscuring Narcolepsy Type 1: A Nine-Year Longitudinal Case Report
Abstract
Obstructive sleep apnea (OSA) is a common disorder whose clinical expression and daytime sleepiness may evolve over time, particularly in the presence of coexisting sleep disorders. We report a nine-year longitudinal case of a 29-year-old man presenting initially with severe excessive daytime sleepiness (EDS) (Epworth Sleepiness Scale (ESS) score: 19/24) and mild OSA (apnea-hypopnea index (AHI): 10 events/h), who represented nine years later with disabling sleepiness, weight gain (body mass index: 30.2 kg/m²), and typical cataplexy. No documented sleep medicine follow-up or OSA treatment was available during the intervening nine-year period. Repeat polysomnography demonstrated moderate, rapid eye movement (REM)-predominant OSA (AHI: 20.4 events/h; REM-AHI: 52.9 events/h; non-REM (NREM)-AHI: 9.4 events/h; REM-AHI/NREM-AHI ratio: 5.6), with increased sleep fragmentation. The Multiple Sleep Latency Test (MSLT), performed after diagnostic polysomnography and before continuous positive airway pressure (CPAP) optimization, showed severe objective sleepiness (mean sleep latency: 3.7 minutes) with sleep-onset REM periods in all five nap opportunities. In the setting of typical cataplexy, these findings strongly supported a diagnosis of narcolepsy type 1; however, untreated OSA and sleep fragmentation at the time of testing were acknowledged as potential confounders in the interpretation of the MSLT. Management included fixed-pressure CPAP at 8 cm H₂O, sertraline for cataplexy, and…
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