Sleep apnoea syndrome--a too frequent misdiagnosis.

Sir, A 45 year old woman, experienced progressive deterioration of memory, loss of concentration, anxiety, tiredness, insomnia with nightmares and arousals characterized by unexplained fear and, rarely, thoughts of suicide. She developed a profound depression, so that 2 months later in November 1987 she decided to discontinue herjob in the stock market. A diagnosis of menopausal-related anxious depressive syndrome was made by her general practitioner and confirmed by two psychiatrists. However neither ethynyl oestradiol, imipramine or diazepam relieved her symptoms. From January to April 1988 two further therapeutic trials with trazodone and tranylcypromine were unsuccessful. In January 1988, she consulted an internist who noticed that her voice had a peculiar timbre, consistent with upper airway obstruction. Examination revealed narrowing of the oropharyngeal airway by excessive folds of the soft palate: fibreoptic examination excluded any coexistent hypopharyngeal or laryngeal obstruction. Polysomnography demonstrated a typical pattern of obstructive apnoea,' with 49 obstructive episodes per hour characterized by arterial oxygen desaturation up to 35%. The most severe of these episodes were terminated by sudden arousal and the presenting symptoms. Application of continuous positive airway pressure' resulted in a dramatic decrease of both frequency and severity of desaturation episodes. The patient recovered her sense of well-being and resumed her job. Uvulopalatopharyngoplasty3 resolved her problem definitively. In the last year, we have observed three further cases of misdiagnosed sleep apnoea syndrome with various clinical presentations. Unfortunately, medical textbooks do not reflect the increasing interest in this subject in medical journals. Thus only halfa page is given up to the sleep apnoea syndrome in the last edition of probably the most authoritative textbook of internal medicine.4 Owing to the high prevalence of this syndrome in the general population, both general practitioners and specialists should become familiar with its multiform clinical presentation. Raffaele Antonelli Incalzi Antonellla Gemma Oliviero Capparella Istituto di Clinica Medica, Universita Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Roma, Italy.