The Kleine-levin Syndrome : Review and Report of Two Atypical Cases

The Klcinc-Levin Syndrom!' (KLS), a type of periodic hypersomnia, typically occurs in young males presenting with episodes of somnolence, excessive eating and abnormal behaviour. In contrast to other hypersomnias, this is a 'long-cycle hypersomnias' with intervals of months of years between episodes (Lishman, 1987). Bonkalo (1968) alludes to Epimenides, a Cretan poet of the sixth century B. C , as a possible candidate for the KLS. Antimoff (1898) described a 19 years old male who suffered from the triad of symptoms mentioned above. Levin (1936) was the first to make mention of i a syndrome of periodic somnolence and morbid hunger as a new entity in nosology" and believed that 10 such cases had till then been recorded, including two by Klein (1925). Critchley and Hoffman (1942) were the first to designate this disorder as the Kleine-Levin Syndrome. In a classic review, Critchley (1962) discussed all the cases reported till then and was convinced of the existence of 26 genuine cases, of which 11 were contributed by himself. In contrast, Oswald (1969) and Pai (1950) were not entirely convinced of the existence of the KLS as a distinct clinical entity. Oswald referred to the psychological (schizophreniform) symptoms associated with the attacks in case described by Critchley (1962). Hartmatm (1985) estimates that about 100 cases with the clinical features of the KLS have been described. The infrequent occurrence of this syndrome has been highlighted in a study by Sours (1963) who was unable to detect a single case while reviewing evaluations for hypersomnia at the Columbia Presbyterian Medical Center between 1932 to 1961. No other epidemiological study appears to have been reported in this regard. The classical clinical description is of a young male with onset of illness between 10 and 20 years of age and manifesting hypersomnia, megaphagia and abnormal behaviour. It usually develops over a well adjusted premorbid personality. Alleged precipitating factors have been described, ranging from psychological insults to gross head trauma. Generally lasting around one week per episode, these attacks remit spontaneously, often with a residue of psychological symptoms which also disappear on their own. Inter-morbid periods are normal and the disorder disappears with passage of time. Hypersomnia and megaphagia are the two major diagnostic symptoms. They have been reported in all the Indian cases (Prabhakaran et al., 1970; Narayanan e ta l . , 1972; Agarwal and Agarwal., 1979 & Shukla et al., 1982). Orlosky (1982) reviewed 33 well-documented cases of K L S and was of the opinion that the KLS may be a mirror-image of Anorexia Nervosa. He found irritability to be the most common mood disturbance (57%). Euphoria and depression were found in 2 1 % of cases only. Confusion was commonly observed (72%) and amnesia for the attack was present in 3 9 % of cases. Imageries, hallucinations, sexuo-sadistic dreams, ideations and acts have been reported. The somnolence