Sleep - American Association of Sleep Technologists

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Publication of the Association of Polysomnographic Technologists • Summer 2006 • www.aptweb.org Sleep and the Immune System BY EDWIN CINTRON, RPSGT AND KORNELIA DENEAU, RPSGT It is often wondered how it is that some people are more at risk of catching colds, viruses, and other common illnesses while others do not. It is obvious that this is directly affected by the body’s immune system, but sleep may play a major part. The amount of restorative sleep one is able to acquire plays a crucial role in strengthening the immune system. Making sure you get plenty of rest is not just an old wives’ tale after all. There are no proven medications available that help to strengthen the immune system 1 . This makes it important to lead a healthy lifestyle, which includes getting enough sleep. No one is really sure about the function of sleep as far as its role in the healing process, but body temperature appears to be important. Rats that are chronically deprived of sleep show increases of 10° C, or more 2 . This suggests that sleep has cooling functions. Conversely, rats deprived of sleep for two weeks or more show a significant drop in body temperature suggesting that sleep may also have a role in heat retention 2 . Studies of sleep deprivation done by Dr. Allen Rechtshaffen, et al, have shown that this constant drop in body temperature leads to death after 11-22 days in rats 3 . It is estimated that it would take as long as 7 months of complete sleep deprivation to result in death for humans 3 . A good, deep sleep (delta sleep, in particular) allows the body to produce more growth hormones. This, in turn, helps the body to rebuild the immune system. Loss of restorative sleep can lead to many different diagnoses including the flu, colds, or other illnesses. One theory suggests that the tiredness associated with the illness may be the body sending a message 4 . The message is simple. Sleep is needed. So why is sleep so important? To answer this, one must consider that when asleep, the human body is using less energy for other things. It can devote more energy to attack invading bacteria and/or viruses more effectively. In older adults, the ability to fight off infection is not as good as it is in younger adults 5 . In response to an infection, one of the body’s defense mechanisms is to increase body temperature (fever) to kill the cells causing the illness 5 . Since the amount of slow wave sleep is less in older adults 6 , this could explain why the immune system is weaker in the elderly. The amount of slow wave sleep in early adulthood (age 16-25 years) is about 18.9%, and it drops to 3.4% during middle age (age 36-50 years) 7 . Healthy sleep also plays a very important role from infancy through adolescence. The impact of poor sleep becomes apparent with this population in a diverse manner. The lack of restorative sleep affects not only the health of the child but also the physical stature. The need for sleep and the repair of tissues is key for further growth. It is well known that in normal subjects, growth hormone is released during sleep in a pulsatile pattern with peaks during slow-wave sleep 8 . We also know that the percentage of slow-wave sleep is increased during the developmental years 8 . In pre-pubertal children, secretion of the growth hormone is clearly coupled with sleep onset 9 . It peaks during the first third of the night, during slow wave sleep, and is secreted exclusively during other stages of sleep 9 . To better understand the consequences of poor sleep in the pediatric population, one can take into consideration the health issues of those with Down Syndrome (DS). Children with DS have been reported to have severe growth arrest and Microcephaly 10 . Additionally, it should be considered that many patients with DS have been reported to present with obstructive sleep apnea 11 . Given the above sleep alterations, the relationship between sleep structure and growth hormone production during sleep is strongly suspected in this population 12 . Growth hormone release is known to be 16 reduced in children with sleep apnea, probably due to the consequent sleep fragmentation 12,13 . Growth hormone production can become normalized if the sleep apnea is effectively treated 14 . Aside from the physical status, sleep deprivation has an effect on a patient’s mental status as well. When a person is Kornelia Deneau severely sleep deprived, this has been known to lead to irritability, hallucinations, psychosis, etc... It has been shown that sleep deprivation leads to delusional thoughts and hallucinations as what was seen when Peter Tripp stayed awake for 201 hours in 1959 15,16 . What makes this remarkable is some believe that recovery of these symptoms comes after just one night of sleep 3 . For clinical depression, sleep deprivation has been used as a treatment as well. 40-60% of cases showed significant and rapid improvement of symptoms by utilizing sleep deprivation as a form of treatment for Edwin Cintron depression 17,18 . The portion of sleep that seems to offer the highest amount of restitution again appears to be slow wave sleep, not only for immunity, but for the mental status as well 19 . There are other medical conditions that have been attributed to a lack of sleep. For example, if a person sleeps for too little or too long, it can lead to symptoms of Diabetes Mellitus 20 . Sleeping less than 6 hours, or for more than 9 hours, has been linked to this metabolic inability to stabilize glucose levels 20 . One study showed that when subjects were only allowed to sleep for only 4 hours per night, an 18 year old could not metabolize their glucose level any better than an 80 year old 21 . Hypertension, also, has been linked to not getting an adequate amount of sleep 22,23 . 80% of the growth hormone, which is important in healing and muscle regeneration, is released during delta sleep 24 . Since Fibromyalgia patients show a decreased level of delta sleep, this may contribute to the muscular pain involved in this muscle disorder 25 . Fibromyalgia is a chronic musculoskeletal pain disorder, which, to date, has no FDA approved treatment to help with symptoms 26 . The fact that some people become ill more often than others may be related to the fact that some people show more delta sleep than others. There are no known medications that improve immunity. However, slow wave sleep is most important in boosting the immune system, and exercise has been shown to increase the amount of slow wave sleep 3 . It is estimated that 47 million adults in the United States do not get the required amount of sleep 27 . This puts everyone at risk of health problems because the immune system is not able to repair itself without an adequate amount of sleep. ★ References 1. The Immune System. 9 July 2006. http://en.wikipedia.org/wiki/Immune_system 2. Rechtschaffen, A. and Siegel, J.M. Sleep and Dreaming. Principles of Neuroscience. 4th Ed. 936-947, New York, 2000. http://www.npi.ucla.edu/sleepresearch/SleepDream/sleep_dreams.htm continued on page 22
Publication of the Association of Polysomnographic Technologists • Summer 2006 • www.aptweb.org The Tsetse Fly and Sleeping Sickness BY WAYNE PEACOCK, RPSGT, UNITED KINGDOM CORRESPONDENT American soil, for the most part, is fortunate not to be riddled with insects and various pests that can carry potentially life altering or threatening diseases. Unfortunately, for Africa it is not. Who would believe that a tiny fly could inflict upon its unwilling victim a disease of sleepiness? The tsetse fly is one that should be avoided at all costs. As a carrier of Trypanosoma brucei rhodesiense (tri-PAN-o-SO-ma BREW-see-eye rho-DEE-see-ense) 3 , this harmless looking fly can inflict pain and discomfort beyond belief. The parasite carried by the tsetse fly manifest in its host as a disorder aptly named African trypanosomisasis, more commonly known as African Sleeping Sickness. There are two types of African Trypanosomiasis, each named for the region of Africa in which they are found. The variety found in Central and East Africa is called Rhodesian and the Central and West African variety is Gambian. There are slight variations in the two versions, I will address the Rhodesian variety with occasional comparison to the Gambian version. Across the globe, there are approximately 40,000 new cases of both East and West African trypanosomiasis reported to the World Health Organization 3 each year. It is believed that the majority of cases are not reported due to a lack of infrastructure and there are more than 100,000 new cases annually (CDC website). Since 1967, twenty-one cases of African trypanosomiasis have been reported within the United States, mainly from holiday makers to the area of Africa in which the tsetse is indigenous 3 . The tsetse fly, common only to Africa, is able to bite through thin clothing. The fly is attracted to bright colours and dust created by moving vehicles and wild animals. They are less active during the hottest part of the day and often rest in bushes but they will bite during this time if disturbed. Infection transmitted by the tsetse fly is common in parts of eastern and central Africa, including Uganda, Kenya, Tanzania, Malawi, Ethiopia, Zaire, Zimbabwe, and Botswana 1 . The bite of the tsetse fly is often painful and may develop into a red sore that is called a chancre (SHAN-ker) 3 . The infected person may develop fever, severe headaches, irritability, extreme fatigue, swollen lymph nodes and aching muscles and joints 2 . Some may also develop a skin rash. As symptoms progress the victim will become confused and exhibit personality changes and is often accompanied by slurred speech, seizures, and difficulty in walking and talking. As a general rule these symptoms are a sign that infection has invaded the central nervous system. If untreated, symptoms will exacerbate and death will occur within six months 2 . The Gambian version of this illness could take up to two years before symptoms develop as it is less aggressive. Symptoms will present within one to four weeks after exposure. The illness develops in two stages. Stage one usually manifests two to three weeks after the redness and swelling occur. This develops as the parasite is carried through the blood and lymph circulation of the host. This systemic phase of the illness is characterised by a fever that spikes high, falls to normal, then respikes. An itchy rash may be present at this point, along with headache and mental confusion. The Gambian form will include swelling of the lymph tissue with enlargement of both the spleen and liver. During this stage there may be an inflammatory reaction of the heart 2 . Stage two of the illness involves the nervous system. The patient begins to experience slurred speech and impaired mental processes. He or she will often sit and stare for extended periods of time, or simply sleep 3 . Those inflicted with the Gambian version may complain of drowsiness during the day and bouts of insomnia at night. Some symptoms resemble Parkinson’s Disease, including shuffling gait, unsteady walking, trembling of the limbs, involuntary muscle movements, and increasing mental confusion. If untreated these symptoms will progress and eventually are followed by coma and ultimately death 1 . In order to properly diagnose this disease series of laboratory tests and a Wayne Peacock spinal tap are needed. Blood smears will generally demonstrate motile trypanosomes in the blood and a spinal tap will demonstrate the same in the cerebrospinal fluid 3 . Laboratory testing will show low red blood cell count, elevated globulin levels, low albumin levels and an elevated ESR 3 . Treatment is available through the CDC and hospitalisation is required due to the fact that the medications required to combat the parasite all have significant potential side effects for the patient. Suramin, eflornithine, pentamidine, and several asenic containing drugs are all effective anti-trypanosomal agents 3 . Once treatment is complete the victim will need follow-up for two years with routine spinal taps to ensure the parasite has been successfully eliminated. There are currently no vaccines for this parasite and the immune system is not capable of building up a resistance once you have been infected. The most effective way to avoid this deadly parasite is prevention and precaution when travelling to the regions mentioned above. To protect against tsetse fly bites, the CDC recommends wearing thick, khaki or olive coloured clothing, using a bed netting when sleeping, insect repellent (this has not proven effective against the tsetse fly, but will help avoid other bites and infections), inspecting vehicles for tsetse flies before entering, not riding on the back of pick-up style trucks or in open jeeps, and avoiding bushes. Those at highest risk for contracting East African trypanosomiasis are tourists, hunters, game wardens, and other persons working or visiting game parks in East and Central Africa 3 . ★ References 1. McGovern TW, William W, Fitzpatrick JE, et al. Cutaneous manifestations of African trypanosomiasis. Arch Dermatol 1995;131:1178-82. 2. Bryan R, Waskin J, Richards F, et al. African trypanosomiasis in American travelers: a 20- year review. Travel Medicine. Steffen R, Lobel HO, Haworth J, Bradley DJ, eds. Berlin: Springer-Verlag, 1989:384-8. 3. Internet Resource http://www.cdc.gov/ncidod/dpd/parasites/trypanosomiasis/factsht_ea_trypanosomiasis.htm. Accessed 12 September 2005. 4. Internet Resource http://www.healthatoz.com/healthatoz/Atoz/ency/sleeping_sickness.jsp. Accessed 19 Septmber 2005. 5. Internet Resource http://www.nlm.nih.gov/medlineplus/ency/article/001362.htm. Accessed 01 October 2005. About the Author Wayne Peacock, RPSGT has been living and working in the United Kingdom since October 2001. He is an active member of the British Sleep Society and serves as the Coordinator for the Pediatric Special Interest Group. Peacock recently joined the Respironics UK team as a Business Manager for Sleep and Home Care Products in the South East of England. He was also a key member in the discussions for implementing the Board of Registered Polysomnographic Technologists registry examination in the UK. 17
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