1247 One Thing Leads to Another. Sleep Testing Opens a Pandora’s Box.

Abstract

Sarcoidosis is a multisystem granulomatous disorder. Pulmonary sarcoidosis can cause lung manifestation and may be at higher risk of obstructive sleep apnea (OSA). A 55 year-old patient presented with snoring, witnessed apneas and daytime somnolence. She had sarcoidosis with pulmonary involvement, fibromuscular dysplasia, and rheumatoid arthritis. She complained of intermittent diaphoresis, constipation, frequent falls and cognitive impairment. Sleep history suggested occasional sleep initiation/maintenance insomnia, leg movements during sleep, sleepwalking and non-injurious dream enactment behavior. Epworth sleepiness scale score was 14. Physical examination showed labile blood pressure, neck circumference of 38 cm, Freidman class III oropharynx, decreased bilateral breath sounds, and unsteady gait. Echocardiography, cardiac stress test, nerve conduction and electromyography were unremarkable. Pulmonary function testing revealed a mild obstructive pattern with normal inspiratory/expiratory loops. Attended polysomnography (PSG) showed mild OSA with an apnea-hypopnea index of 7 per hour, worse on the back and in rapid eye movement (REM) sleep, with low baseline oxyhemoglobin saturation. Inspiratory stridor was observed in the supine position. Periods of REM sleep without atonia were noted, but no dream enactment behavior. Continuous positive airway pressure therapy was initiated at 8 cm of water pressure. Due to these findings on sleep history and PSG, she was scheduled to undergo brain MRI, vocal cord exam and respiratory muscle strength testing. PAP therapy effectively controlled her OSA. Sleep medicine evaluation was sought for possible OSA. Detailed history uncovered additional symptoms that led to the suspicion of sarcoid involvement of the nervous system. PSG revealed stridor and possible hypoventilation, raising the possibility of involvement of the vocal cords and diaphragm respectively. This case emphasizes the importance of a detailed history in a sleep evaluation. PSG often diagnose sleep disordered breathing, but as in this case, can reveal possible progression of the underlying disease.