1433 Paradoxical Insomnia, Visual Snow Syndrome, and Ozone Toxicity: How Are They Connected?

Janey Dudley; Daniel Rongo; Likhita Shaik; Michael Ibarra

doi:10.1093/sleep/zsaf090.1433

Introduction Paradoxical insomnia is insomnia disproportional to the presence of objective sleep disturbance or daytime impairment. Hypervigilance occurs while patient is trying to sleep, suggesting paradoxical insomnia has a hyperarousal component, and there may be physiological or perceptual deficits that affect sleep/wake discrimination causing sleep time underestimation. Visual snow is a recently identified neurologic condition consisting of a constant visual disturbance described as multiple dots over the entire visual field. Visual snow syndrome occurs when, in addition to visual static, patients also report palinopsia, entoptic phenomena, photophobia, and nyctalopia. With pollutant ozone toxicity, well-established evidence has been produced for short-term effects, especially on respiratory and cardiovascular systems. Unfortunately, ozone therapy has mostly been studied in the setting of environmental exposures, less so in alternative medicine settings. Report of case 41 year old female with history of anxiety, depression, visual snow syndrome, and recent ozone toxicity presented to hospital for pain, vision changes, weakness, and insomnia. Two months before presentation, patient was receiving IV ozone therapy repeatedly that led to suspected ozone toxicity. Days later, patient was diagnosed with visual snow syndrome by neuro-optometrist. Lack of sleep for the following two months prompted hospital presentation. Patient described inability to sleep, but explained entering a “twilight state” where she dreamed, but could hear her surroundings. 24 hour EEG confirmed patient was sleeping and ruled out nocturnal seizures. Free radical damage from ozone toxicity could lead to thalamic injury, but none was seen on functional MRI. With normal testing/imaging and based on descriptions of this “twilight” state, her symptoms were consistent with paradoxical insomnia, so she was discharged from hospital on Valium 5mg TID, Ambien 20mg nightly, and Lyrica 125mg nightly – despite these medications, she reported she was still unable to sleep. In outpatient follow up, she had a normal polysomnogram and actigraphy consistent with paradoxical insomnia. Over the next few months, medications were weaned, and patient was treated for paradoxical insomnia. Conclusion This case portrays multiple rare diagnoses in one patient with a relatively common sleep diagnosis. It also highlights the role polypharmacy plays in treatment for neurological and psychiatric complaints.

1433 Paradoxical Insomnia, Visual Snow Syndrome, and Ozone Toxicity: How Are They Connected?

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