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We describe the case of a 12-year-old boy who developed temporal lobe epilepsy (TLE) with daily complex partial seizures (CPS) and monthly generalized seizures. Moreover, he frequently snored while asleep since early childhood. Polysomnography (PSG) revealed severe obstructive sleep apnea with apnea–hypopnea index (AHI) of 37.8/h. Video-PSG with simultaneous electroencephalography (EEG) recording captured two ictal apneic episodes during sleep, without any motor manifestations. The onset of rhythmic theta activity in the midtemporal area on EEG was preceded by the onset of apnea by several seconds and disappeared soon after cessation of central apnea. One episode was accompanied by ictal bradycardia of < 48 beats/min which persisted for 50 s beyond the end of epileptic activity. After treatment with carbamazepine and tonsillectomy/adenoidectomy, the seizures were well controlled and AHI decreased to 2.5/h. Paroxysmal discharges also disappeared during this time. Uncontrolled TLE complicated by sleep apnea should be evaluated for the presence of ictal central apnea/bradycardia.

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Context It is well known that Graves’ disease (GD) causes sleep disorders (SD). However, the characteristics and associated factors of SD and its clinical course post-hyperthyroidism normalization remain unclear. Objective To clarify the characteristics and associated factors of subjective SD and its clinical course after GD treatment. Design, setting, and study participants From November 2017 to October 2020, we enrolled 72 participants (22 newly diagnosed with GD with untreated hyperthyroidism, 20 previously diagnosed with GD with normal thyroid function, and 30 normal controls) with no other underlying sleep disorder-related diseases. We compared the groups at enrollment and conducted prospective observations after 12 months of treatment on participants with newly diagnosed GD. Main outcome measures Differences and changes in the Pittsburgh Sleep Quality Index (PSQI) global and component sleep quality scores. Results PSQI global sleep quality scores (p = 0.036) and sleep disturbance scores (p = 0.011) were significantly different among the three groups, and were highest in the untreated hyperthyroidism group. Multiple regression analysis demonstrated that free thyroxine level, which was positively correlated with sympathetic tone (ST) as evaluated by pulse rate and urinary total metanephrines, was associated with poorer PSQI global sleep quality scores independently of other factors (p = 0.006). Prospective observation showed that PSQI global sleep quality scores (p = 0.018) and sleep disturbance scores (p = 0.011) significantly improved with thyroid function normalization and ST attenuation. Conclusions Hyperthyroidism caused by GD augmented ST and exacerbated subjective SD. Normalization of hyperthyroidism caused by GD improved subjective SD.

Background: The prevalence of obstructive sleep apnea (OSA) is increasing and is related to obesity, hypertension and cardiovascular events. Hormonal abnormalities due to hypothyroidism and large goiter can cause OSA. However, the association between OSA and Graves' disease (GD) is not studied well. GD is a major cause of thyrotoxicosis associated with various symptoms like weight loss, palpitations, and hyperhidrosis. After the treatment for normalizing thyroid function, patients sometimes experience metabolic abnormality, like weight gain and dyslipidemia. The objective of our study is to explore clinical characteristics of OSA coexisting with GD. Patients and Method: Patients diagnosed as GD with normalized thyroid function by anti-thyroid medications, radioiodine therapy, and surgery were enrolled from September 1st, 2017 to September 30th, 2018 in accordance with written informed consent. Normal thyroid function was defined by serum Free T4 level ranging from 0.8 ng/dL to 1.7 ng/dL. Patients were undergone polysomnography, and OSA was defined by apnea-hypopnea index greater than 5 times/hour. Patients were divided into 2 groups according to the existence of OSA. Patient’s profile including age, physical signs, disease duration from diagnosis to entry, thyroid function test, and data from polysomnography were obtained and analyzed between the two groups. Results: Sixteen patients aged 46.4 ± 13.0 years (2 male,14 female) were included in this study. Eight of 16 patients (50 %) were categorized into OSA positive group (OSA+). There were no significant differences between OSA+ and OSA negative group (OSA-) in gender, body mass index (BMI), disease duration, and thyroid function test, though BMI tended to be higher in OSA+ (data not shown). Mean Age of OSA+ was significantly higher than that of OSA- (53.6 ± 12.0 vs 39.3 ± 10.0 years, p < 0.05). In addition, systolic blood pressure (136.8 ± 10.0 vs 117.9 ± 11.8 mmHg, p <0.05) and diastolic blood pressure (79.4 ± 5.2 vs 70.3 ± 6.5 mmHg, p <0.05) of OSA+ were significantly higher than those of OSA-. Conclusions: Our findings suggested that the prevalence of OSA in GD after normalizing thyroid function might be higher than that of general populations in Japan. Furthermore, OSA was experienced in GD with higher age and higher blood pressure, even though their thyroid function was normalized. Persistent hypertension after normalizing thyroid function may be associated with OSA especially in elderly patients with GD.