Rapid Weight Gain in an Excessively Sleepy Girl With Asthma

Timothy D. Murphy, MD

Disclosures

October 09, 2020

Physical Examination and Workup

The patient has fallen asleep at school nearly every day for the past 1-2 months and falls into a deep sleep unless she is kept active. At home, she is taking more naps during the day, falling asleep in the car, and struggling with schoolwork. Her grades have dropped significantly over the past few months. Her parents report that she does not awaken during the night. No snoring, choking, snorting, gasping, or apnea is noted. She sleeps an average of 9-10 hours per night but is restless and tosses and turns frequently in her sleep.

Her family history is notable for obesity, obstructive sleep apnea (OSA) that requires continuous positive airway pressure (CPAP) in her father, and narcolepsy in an uncle and a grandfather.

On physical examination, she has mild to moderate obesity (BMI of 23.89 kg/m2 [the 98th percentile for age]) and enlarged tonsils (2-3+). She has difficulty with focusing and staying awake in the clinic.

She is referred to a pediatric otolaryngologist for consideration of nocturnal polysomnography (NPSG) or an adenotonsillectomy. The otolaryngologist notes that she has not tolerated nasal fluticasone well, that she is a chronic mouth breather, and that her tonsils are enlarged (3+). An NPSG is ordered to help clarify matters.

The NPSG demonstrates the following:

  • A respiratory disturbance index and an apnea-hypopnea index (AHI) of 6.2 per hour

  • Sleep latency of 0.5 minutes and rapid eye movement (REM) latency of 0.5 minutes

  • A sleep efficiency of 87.5%

  • 18.2% of total sleep time in stage N1, 36.4% in N2, 29.9% in N3, and 15.5% in REM sleep

  • An arousal index of 18.6

  • A periodic leg movement index of 6.3

  • Multiple periods of wakefulness scattered throughout the night and six REM periods

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