Resolution of night terrors after discontinuation of cetirizine

doi:10.4236/crcm.2012.11001

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Vol.1, No.1, 1-2 (2012) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2012.11001

Resolution of night terrors after discontinuation of

cetirizine*

Lourdes DelRosso#, Romy Hoque

Department of Neurology, Division of Sleep Medicine, Louisiana State University School of Medicine, Shreveport, USA;

#Corresponding Author: [email protected]

Received 15 July 2012; revised 22 August 2012; accepted 10 September 2012

ABSTRACT

We present a 4-year-old girl with allergies and

asthma who developed night terrors after initia-

tion of montelukast at 2 years of age. Montelu-

kast was discontinued and cetiri zine was started.

Nigh terrors persisted. Sleep diaries were col-

lected and diagnosticpolysomnogram (PSG)

was ordered. Sleep diaries revealed an average

sleep time of 10 hours with night terrors occur-

ring three nights a week approximately two

hours after sleep onset. The PSG did not show

evidence of sleep disordered breathing or peri-

odic leg movements. Cetirizine was discontin-

ued and the night terrors ceased. Upon re-intro-

duction of the medication, the sleep terrors re-

curred.

Keywords: Night Terrors; Montelukast; Cetirizine;

Allergic Rhinitis

1. INTRODUCTION

Night terrors are common in pediatric populations

with a prevalence of 14.7% in children 3 - 10 years of

age [1]. Night terrors usually arise from slow wave sleep

(N3); start with a loud scream; are accompanied by

autonomic nervous system manifestations; and have been

associated with stress, gastro-esophageal reflux (GERD)

and sleep disordered breathing. We present a case of

night terrors in a pediatric patient after initiation of the

commonly used allergy medications montelukast and

cetirizine while already on beclamethasone. Cetirizine is

a second-generation antihistamine that crosses the blood

brain barrier. Montelukast is a leukotriene receptor an-

tagonist used for asthma and seasonal allergies. Becla-

methasone is a corticosteroid used as a nasal spray for

allergic rhinitis, and used as an inhaler for asthma. The

night terrors resolved after discontinuation of montelu-

kast and cetirizine.

2. CASE REPORT

A 4-year-old girl presents for evaluation of nocturnal

episodes consisting of abrupt awakening with screaming

and confusion lasting fifteen minutes in duration and

occurring three nights a week. The child usually returns

to sleep without difficulty following each event. She de-

nies dream recall or memory of the event upon awaken-

ing in the morning. The events began at 2 years of age

after initiation of montelukast for seasonal allergic rhini-

tis with nasal congestion and occasional snoring. The

montelukast was discontinued and cetirizine 2.5 mg a

day was initiated. The patient’s only other medications

were beclomethasone 40 mg two puffs daily, and al-

buterol 50 mcg inhaler as needed for asthma.

The patient’s asthma started at 1 year of age, is well

controlled with the beclamethsaone and albuterol. No

nocturnal asthma exacerbations/symptoms were reported.

Other past medical history includes bilateral otitis media

and GERD. Surgical history includes tonsillectomy and

adenoidectomy at 2 years of age with subsequent im-

provement in snoring.

Family history is negative for parasomnias. Review of

systems was positive for: snoring, nasal congestion and

post-nasal drip; and negative for: behavioral disturbances,

excessive daytime sleepiness, sleepwalking, sleep talking,

stereotypic movements or restless legs.

Physical examination revealed a child in no distress

with a body mass index of 18. Nasal mucosa waserythe-

matous with boggy turbinates. Oral airway exam re-

vealed a Mallampati score of IV, with no tonsils noted.

The remainder of her physical and neurological exami-

nation was unremarkable. Radioallergosorbent test (RAST)

testing was negative for common animal, grass and weed

antigens.

Diagnostic polysomnogram (PSG) revealed a sleep la-

tency of 47 minutes; sleep efficiency of 89% and arousal

index of 7. Apnea-hypopnea index (AHI) was 0.4. The

*The authors declare that they do not have any conflict of interest. The

arents of the patient signed a consent for publication of this case re-

ort.

L. DelRosso, R. Hoque / Case Reports in Clin ical Medicine 1 (2012) 1-2

minimum oxygen desaturation was 96%. There was no

evidence of snoring, hypoventilation, or abnormal noc-

turnal behaviors. Sleep diaries revealed an average noc-

turnal sleep time of 10 hours with no daytime napping.

Night terrors were noted between midnight and two am.

Cetirizine was stopped and night terrors ceased. After

three weeks, cetirizine was re-introduced with recurrence

of sleep terrors.

3. DISCUSSION

The International Classification of Sleep Disorders-

second edition, defines night terrors as sudden episodes

of terror during sleep, usually initiated by a cry or loud

scream, accompanied by autonomic nervous system and

behavioral manifestations of intense fear. The diagnostic

criteria must include at least one of the following: diffi-

culty in arousing the patient, mental confusion when

awakened from the episode, amnesia for the episode, and

potentially dangerous behaviors. The condition must not

be related to another sleep disorder; medical, mental or

neurological condition; medication or substance use [2].

Sleep terrors are a common parasomnia, sometimes

confused with nightmares. Genetic factors, sleep depri-

vation, stress and fever play an important role in their

manifestation [3,4]. Sleep terrors occur in the first couple

of hours of sleep and usually arise from N3. Any disrupt-

tive factor during N3, such as obstructive sleep apnea

(OSA), may trigger sleep terrors [5].

Allergic rhinitis affects approx imately 40% o f child ren.

Medications used for the treatment of allergies include:

corticosteroids, antihistamines, leu kotriene modifiers and

mast cell stabilizers. Both cetirizine a second-generation

oral antihistamine, and montelukast, a selective leukot-

riene receptor antagonist, minimally cross the blood

brain barrier. Prior reports have demonstrated a strong

association between montelukast and nightmares. [6].

Insomnia and nocturnal awakenings have been reported

with cetirizine. [7].

4. CONCLUSION

Night terrors in our patient were attributed to cetirizine

due to the resolution of symptoms after discontinuation

of the medication and recurrence of symptoms after re-

introduction of cetirizine. The mechanism of sleep ter-

rors with cetirizine may be secondary to arousals from

N3. Our patient remains symptom free after discontinua-

tion of cetirizine. This case highlights the importance of

evaluating for possible medication effect with sudden

onset parasomnias.

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