Status dissociatus and disturbed dreaming in a patient with Morvan syndrome plus myasthenia gravis

Abstract

A 52-year-old patient suffered from myasthenia gravis with antibodies against acetylcholine receptors and a thymoma, and was successfully treated with surgery, radiotherapy, and azathioprine. At age 60, he experienced non-painful cramps and myokymia in the calves, which progressively spread to the whole body, associated with profuse sweating, non-restorative sleep, and dream-enacting behaviors. Because of dysphagia and dysarthria, he was admitted to the intensive care unit. As there were continuous resting activities with fasciculations andmyokymia but no myasthenia decrement in the electromyography, no malignant thymoma, and no paraneoplastic antibodies, Morvan syndromewas suspected and later confirmed by positive antibodies against contactin-associated protein-like 2. His wife reported that he displayed continuous motor restlessness during the night for the past year. The patient slept on average for 7 h at night and had two 30-min-long naps per day. He always felt “mid-water, neither awake nor asleep,” being conscious throughout the night and yet experiencing an intense and continuous dreaming activity, including epic dreaming (eg, fantastic, prolonged rides in a hot air balloon with gypsies), vivid dreaming (eg, he repeatedly dreamt that his son was cheating on his wife; the dreams seemed so real that he felt obliged to inquire from his son), lucid dreaming (he knew sometimes that he was dreaming), and recurrent contextual dreams. As he was scheduled for a brain scan, he vividly dreamt that the nurses entered his hospital room to bring him to the scanner. As he stood up and put his slippers, he realized that it was 3 am, resumed sleep, and dreamt again, but this time the nurses were coming into the room to warn him that the scanner has been rescheduled another day, and so on. During daytime, he felt sleepy needing four to five naps of 30 min each per day, during which dreaming was less vivid than during nighttime. During nighttime videopolysomnography, the electroencephalographic (EEG) activity contained a continuous, diffuse 9-Hz alpha rhythm (as duringwakefulnesswith eye closed) all night long, without any conventional sleep features (theta activity, spindles, * Corresponding author. Service des Pathologies du Sommeil, Hopital PitieSalpetriere, 47-83 Boulevard de l’Hopital, 75651 Paris Cedex 13, France. Tel.: +33 142 16 77 02; fax: +33 142 16 77 00. E-mail address: isabelle.arnulf@psl.aphp.fr (I. Arnulf).