REM sleep behavior disorder initiated by acute brainstem multiple sclerosis

REM sleep behavior disorder (RBD) is defined by loss of normal skeletal muscle atonia during REM sleep, resulting in excessive, often violent motor activity, frequently associated with dreaming.1 RBD is typically a chronic disorder occurring idiopathically or accompanying neurologic disease, particularly the neurodegenerative synucleinopathies of Parkinson disease, multiple-system atrophy, and dementia with Lewy bodies.2 Acute RBD may be associated with alcohol and psychoactive substance intoxication or withdrawal and structural brain lesions. The anatomic lesion site and time course of acute RBD are not well known. We report RBD arising following a severe attack of dorsal pontine demyelination from multiple sclerosis (MS). A 51-year-old woman with MS developed acute vertigo, ataxia, diplopia, dysarthria, and bifacial weakness. She had been in clinical remission for 24 years without immunomodulatory therapy. Following repeated courses of IV corticosteroids and therapeutic plasma exchange (TPE), her symptoms improved markedly, and subcutaneous interferon β-1a was initiated. One week later, the patient’s husband of 28 years described that she exhibited nightly sleep-related groaning, screaming, limb jerking, flailing, and violent thrashing, punching her husband’s jaw once. She did not recall these events or any associated dream content. There were no prior parasomnias or spousal reports of …