Dados do Trabalho

Título

Clinical improvement of REM sleep behavior disorder after the combination of amantadine and quetiapine

Introdução

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia characterized by motor activity during sleep resulting from loss of REM sleep atonia. It is often associated with synucleinopathies such as dementia with Lewy bodies (DLB).

Objetivo

We report a case of a patient with RBD who did not respond to standard treatment and whose condition was completely under control after the combination of amantadine and quetiapine.

Métodos

Clinical data were collected from electronic medical records.

Resultados

A 45-year-old woman was referred to the neurology department reporting frequent nocturnal episodes of restlessness with walking and vocalizations. Upon awakening, she had incomplete recollection of the episodes, and the description of the events were reported to the patient by her mother, with whom she lives. She reported worsening frequency and intensity of the condition after a recent COVID-19 infection, with daily events. She reported previous treatment with no improvement. She described similar episodes in childhood, with complete improvement in adolescence. On physical examination, she showed mild impairment of upper limb balance; other subjects on neurologic examination without changes. Clonazepam 2.5 mg/ml 4 drops was started, and the dosage was increased by 1 drop every 2 days up to 10 drops/day. Transcranial ultrasound of the brain parenchyma, magnetic resonance imaging of the brain, and polysomnography were also requested. Thereafter, the patient reported a worsening of her condition and began to remember her nightmares. The medication was discontinued and quetiapine 25 mg/day was started. Ultrasound measurement of the substantia nigra showed 10 mm2 on the right and 15 mm2 on the left (reference value 25 mm2). Magnetic resonance imaging showed absence of the swallow tail sign. Polysomnography showed no changes, but there was a loss in technical quality because the multiple sleep latency tests were not performed. Then, therapy with amantadine 50 mg/day in combination with quetiapine 25 mg/day was started. She reported significant clinical improvement with a reduction in the frequency of episodes. After a new dose adjustment with amantadine 100 mg/day and quetiapine 25 mg/day, the patient developed stably without new episodes.

Conclusões

Movement disorder may be suspected in patients with spontaneous RBD who do not respond to clonazepam, and amantadine might be a possible therapeutic option.

Palavras -chave

REM Sleep Behavior Disorder, Lewy Body Disease, Amantadine.