All Fall Down

Sleep disorder symptoms are rarely part of the clinical spectrum of paraneoplastic central nervous system disease. Ma1 and Ma2 antibodies involving mesencephalic and diencephalic structures, including the hypothalamus, can result in destruction of hypocretin neurons, leading to narcolepsy type 1 (formerly narcolepsy with cataplexy). This chapter presents a young man with testicular carcinoma and a devastating clinical syndrome of limbic encephalitis, supranuclear palsy, and narcolepsy with cataplexy in the setting of Ma1 and Ma2 paraneoplastic antibodies. Early treatment with removal of the underlying tumor and immunotherapy after several years resulted in a meaningful neurologic recovery. Paraneoplastic disorders should be considered in patients presenting with a subacute onset of narcolepsy in the setting of encephalitis and/or multifocal neurologic deficits.