kleine - levin syndrome ( kls ) is a rare disorder which mainly affects adolescent boys and characterized by recurrent episodes of hypersomnia , and sometime along with hyperphagia , behavioral and cognitive disturbances , and hypersexuality . several medications ( stimulants , lithium , valproate , antipsychotics , and antidepressants ) have been reported to provide variable benefit in different symptoms , with lithium being the most widely used drug . we are presenting a case of kls , who had complete remission with valproate and also reviewing the cases reported from india . a 17-year - old single male student of 12 standard , presented to our psychiatric outpatient clinic in september 2004 with hypersomnolence , low mood , decreased appetite and interest in studies , social and sexual disinhibition ( such as singing obscene songs loudly at home , and touching unconsenting females including mother 's body parts - limbs , face and genitalia ) . onset was acute , without any elicitable precipitating factor and course was episodic with average 7 - 10 days episode in every month for last 4 months and he maintained completely well in inter episodic period . provisional diagnosis of recurrent depressive disorder ( brief episodes ) was kept and he was started on sertraline ( 50 mg ) , on which he responded well . he remained asymptomatic for nearly 9 months , but started having similar episodes again from mid-2005 , due to which sertraline were gradually hiked up to 150 mg / day , but of no use . hence , he was admitted in our inpatient setting in march , 2006 for diagnostic evaluation and further management . after detailed evaluation , it was found that his sadness was not pervasive and depressive cognitions and associated disturbances were not present and hypersomnia remained predominant complaint as initially , he was sleeping 16 - 20 h / day . he was also not responding with these medications , hence differential diagnosis of kls versus depression was kept and later finalized to kls . his hemogram , renal functions , liver functions , blood sugar , routine urine , thyroid functions were within normal limits and chest x - ray , electrocardiography , electroencephalography ( eeg ) , and magnetic resonance imaging brain were normal . in view of good literature support lithium was started from 600 mg / day and hiked to 900 mg / day ( serum level 0.8 meq / l ) . on which he has shown significant improvement initially for 6 months , but later again started experiencing similar symptoms . he also had three episodes of fall , unresponsiveness and epileptiform discharge in eeg twice . hence , in view of seizure disorder and lack of response , neurologist 's consultation was sought , who opined to start antiepileptic medication . hence , lithium was switched to valproate ( 750 mg / day ) in december 2006 , on which he maintained completely well for 4 years , except brief re - emergence of symptoms on discontinuing valproate , which improved completely on resuming the medication . valproate was gradually tapered and stopped in january 2011 on insistence of patient and family with discussing its pros and cons . now index case has been maintaining well - off valproate for last 3 years without any episode of hypersomnolence , sexual disinhibition , sadness , or epileptic seizure . based on historical reports by kliene and levin , kls was essentially described and termed by critchley . thereafter , many researchers have reported their cases and reviewed cases with kls . here , we are reporting a case with kls , who responded well with valproate , after diagnostic dilemma and different psychotropic medications and also reviewing the other cases reported from india . in our electronic search for indian studies on kls , by using pubmed and google scholar , we could find 15 cases reported from india . of them 13 were males and 2 females , similar to male preponderance reported in the literature . while presenting to psychiatric services their age was between 9 and 26 years and they had onset between 7 and 24 years of age . in two - third of patients ( 10 out of 15 patients ) , it was preceded with fever and their episodes of somnolence were lasted from 3 days to 10 weeks . hypersomnia and hyperphagia were present in all , while two - third of patients also had social and sexual disinhibition ( 11 out of 15 patients ) . other symptoms were cognitive disturbances ( low intelligence quotient , impaired memory , confusion , and academic decline ) , irrelevant talk , and perceptual disturbances . nearly one - third of patients improved spontaneously without any medication , while rest was given lithium , carbamazepine , methylamphetamine , dextroamphetamine , and modafinil . longest asymptomatic follow - up period is reported for 2 years [ table 1 ] . reported cases with kls from india though literature supported lithium for higher response rate , but index patient had remarkable response with valproate , not with lithium , like earlier two reports . like earlier report , index patient also improved on lower dose of valproate ( divalproate 750 mg vs. 500 mg valproate ) . compared to other cases reported from india , index patient had longest follow - up ( 7 years ) and remained asymptomatic in this period , except small exacerbation on discontinuation of valproate treatment , which improved completely on resuming the drug . similar to our patient , anticonvulsants ( like valproate ) are the preferred treatment for kls patient , and may also offer benefits in case of comorbid epilepsy . valproate may be a good alternative to lithium in terms of efficacy as well as side - effect profile .
kleine - levin syndrome ( kls ) is characterized by recurrent episodes of hypersomnia and other symptoms and it is a really challenging for the physician , since its causes are not yet clear , and available treatment options are not having adequate support . here , we are reporting a case with successful use of valproate in kls and also reviewing the cases reported from india .