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Sleep, Immunity, and Circadian Clocks: A Mechanistic Model

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The lack of sufficient amounts of sleep is a hallmark of modern living, and it is commonly perceived that in the long run this makes us sick. An increasing amount of scientific data indicate that sleep deprivation has detrimental effects on immune function. Conversely, immune responses feedback on sleep phase and architecture. Several studies have investigated the impact of short-term sleep deprivation on different immune parameters, whereas only a few studies have addressed the influence of sleep restriction on the immune system. In many cases, sleep deprivation and restriction impair immune responses by disrupting circadian rhythms at the level of immune cells, which might be a consequence of disrupted endocrine and physiological circadian rhythms. Little is known about the mechanisms underlying the circadian regulation of immunity, but recent studies have suggested that local as well as central circadian clocks drive the rhythms of immune function. In this review, we present a mechanistic model which proposes that sleep (through soluble factors and body temperature) primes immune cells on the one hand, and, on the other hand, provides a timing signal for hematopoietic circadian clocks. We hypothesize that chronic sleep disruption desynchronizes these clocks and, through this mechanism, deregulates immune responses.
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Gerontology
DOI: 10.1159/000281827
Sleep, Immunity, and Circadian Clocks:
A Mechanistic Model
Thomas Bollinger a Annalena Bollinger b Henrik Oster c Werner Solbach a
a Institute of Medical Microbiology and Hygiene, University of Luebeck, Luebeck ,
b Institute for Immunobiology,
Research Center Borstel, Borstel , and
c Circadian Rhythms Group, Max Planck Institute of Biophysical Chemistry,
Goettingen , Germany
nal for hematopoietic circadian clocks. We hypothesize that
chronic sleep disruption desynchronizes these clocks and,
through this mechanism, deregulates immune responses.
Copyright © 2010 S. Karger AG, Bas el
Introduction
Over the last 25 years, the modern urban lifestyle has
led to a constant decrease in average sleeping time
[1] , re-
sulting in what has been called an ‘epidemic of sleep re-
striction’ ( table 1 ). In the USA and Europe, approximate-
ly 15–20% of the population work at night
[2] , which fre-
quently leads to reduced sleep
[3] . An increasing body of
evidence suggests detrimental effects of chronic sleep
disruption on health and life expectancy. For example,
Kripke et al.
[4] showed in a study of 1.1 million men and
women that both shortened and extended sleep times are
associated with a significantly increased mortality haz-
ard. Furthermore, the common perception that sleep loss
makes us more susceptible to infections is supported by
human and animal studies
[5–7] . On the other hand, in-
fections can also feedback to t he re gulation of sleep, most
likely via proinf lammatory cytokines [for a review, see
8 ].
Strikingly, a comparative analysis of mammalian sleep,
immunity, and parasitism found a strong association be-
Key Words
Sleep Immune Clock Circadian Rhythm Diurnal
Synchrony
Abstract
The lack of sufficient amounts of sleep is a hallmark of mod-
ern living, and it is commonly perceived that in the long run
this makes us sick. An increasing amount of scientific data
indicate that sleep deprivation has detrimental effects on
immune function. Conversely, immune responses feedback
on sleep phase and architecture. Several studies have inves-
tigated the impact of short-term sleep deprivation on differ-
ent immune parameters, whereas only a few studies have
addressed the influence of sleep restriction on the immune
system. In many cases, sleep deprivation and restriction im-
pair immune responses by disrupting circadian rhythms at
the level of immune cells, which might be a consequence of
disrupted endocrine and physiological circadian rhythms.
Little is known about the mechanisms underlying the circa-
dian regulation of immunity, but recent studies have sug-
gested that local as well as central circadian clocks drive the
rhythms of immune function. In this review, we present a
mechanistic model which proposes that sleep (through sol-
uble factors and body temperature) primes immune cells on
the one hand, and, on the other hand, provides a timing sig-
Received: July 2, 2009
Accepted: October 20, 20 09
Published online: Feb ruary 3, 2010
Thomas Bolli nger, MD
Institute of Med ical Microbiolog y and Hygiene, University of Luebeck
Ratzeburger A llee 160
DE–23538 Luebeck (Germany)
Tel. +49 451 50 0 2818, Fax +49 451 500 2808, E-Mail Thomas.Bollinger
@ uk-sh.de
© 2010 S. Karger AG, Basel
0304–324X/10/0000–0000$26.00/0
Accessible online at:
www.karger.com/ger
Bollinger /Bollinger /Oster /Solbach
Gerontology
2
tween longer sleep duration and reduced levels of para-
sitic infections
[9] .
Little is known about how sleep affects immune func-
tion, but we know from long-term sleep deprivation and
restriction in experimental animal models and short-
term sleep deprivation or restriction in human vaccina-
tion studies that sleep improves the immune response
[6,
10, 11] . Furthermore, the analysis of several immune pa-
rameters has shown that sleep loss alters the normal cir-
cad ia n rhy th m s ee n i n man y of these meas ures
[8, 12–15] .
Hence, sleep seems to influence the processes underlying
the circadian immune rhythm. Such rhythms are gener-
ated by cell-autonomous molecular oscillators that con-
trol physiology v ia the orchestration of hundreds of clock-
controlled genes
[16] . Circadian clocks have been de-
scribed in various types of immune cells and the network
properties of the circadian timing system make it a prime
candidate for communication between sleep and im-
mune regulation. In this review, we summarize the cur-
rent knowledge of the interaction between sleep, circa-
dian clocks, and the immune system, and present a mod-
el of how sleep (loss) may affect immune function at
different levels.
Sleep-Immune Interactions
Two basic questions arise: do immune responses mod-
ulate sleep and does sleep, or the lack thereof, influence
the course of an immune response? Several studies have
shown that infections as we ll a s low-do se l ipop olysac cha-
ride administration increase sleep in humans and mam-
mals, most likely through induction of proinflammatory
cytokines [for a review, see
8 ]. Additionally, it was dem-
onstrated that neutralizing tumor necrosis factor-
(TNF- ), a key proinflammatory cytokine, causes sub-
stantially reduced sleepiness in obstructive sleep apnea
patients
[17] . By contrast, in humans, infections with rhi-
noviruses and, to a lesser extent, with Trypanosoma bru-
cei, decrease sleeping times
[18 , 19] . However, rhinovi-
ruses often cause respiratory problems which themselves
can affect sleep. Moreover, Trypanosoma brucei infects
the brain, which might mask the primary effects on sleep
by the infection itself. Nevertheless, from these data it
seems clear that infections affect sleep.
Toth et al. [20] demonstrated that the morbidity and
the mortality of experimentally infected rabbits are de-
creased with a longer sleep duration after the infective
challenge. Furthermore, it was shown that long-term
sleep deprivation as well as restriction in animals leads to
septicemia and can even be fatal [6, 7] . Hence, sleep has a
protective role. Conflicting data have been published on
the impact of sleep on experimental influenza infection
in mice: while some authors found benefits of sleep on the
immune response, other authors observed the opposite
or no effect
[21–23] .
In humans, it has been shown that one night of sleep
deprivation after a hepatitis A vaccination results in de-
creased antibody responses
[10] , and that 4 days of sleep
restriction prior to influenza vaccination also substan-
tially decreased antibody responses
[11] . Furthermore, it
was shown in a correlational study by Cohen et al.
[24]
that reduced sleep increases the risk of acquiring a com-
mon cold. From this experimental evidence, it seems
clear that sleep has beneficial effects in most infections or
vaccination responses.
Several studies have reported immunological altera-
tions related to sleep by using sleep deprivation or restric-
tion paradigms, but the underlying mechanisms remain
elusive. One limitation of human studies is that immune
cells or cytokines in the peripheral blood have been ana-
lyzed, and these might not reflect the changes taking
place in the spleen and lymph nodes. Unfortunately, there
is no good alternative in humans. Most studies have ad-
dressed the influence of sleep on the changes in absolute
and relative leukocyte counts in the blood and the rate of
cytokine-producing cells after polyclonal stimulation
[
13–15 ; for a review, see 8 ]. These studies have elegantly
Tab le 1. Definitions of key terms used in this report
Circadian
rhythm
an endogenous rhythm with a period of approxi-
mately 24 h that persists in the absence of external
timing signals (zeitgeber) such as the light-dark cy-
cle, temperature, or social rhythms
Diurnal
rhythm
a 24-hour rhythm that is tied to an external zeitgeber;
a diurnal rhythm is the representation of a circadian
rhythm under synchronized (entrained) conditions
Sleep
deprivation
experimental paradigm in which a subject is prevent-
ed from sleeping for an extended period of time; in
this review, we use the term for experiments in which
sleep was deprived for a least 24 h
Sleep
restriction
a sleep time reduction below the physiologically re-
quired amount of sleep
For the sake of simplicity, we have not differentiated between
‘circadian’ and ‘diurnal’ rhythms, but have always used the term
‘circadian’ when referring to 24 h rhythms under both free-run-
ning and entrained conditions.
Sleep, Immunity, and Circadian Clocks Gerontology
3
demonstrated circadian rhythms for counts of several
leukocyte subpopulations, including neutrophils, mono-
cytes, dendritic cells, natural killer (NK) cells, B cells, T
cells, and regulatory T cells which are (T cells, B cells, NK
cells, dendritic cells, monocytes) or are not (neutrophils,
regulatory T cells) modulated by sleep. In most of these
cases, sleep loss flattens existing circadian rhythms. This
clearly demonstrates that the analysis of sleep-dependent
changes requires sequential measurements for a period of
at least 24 h. Therefore, studies which investigated sleep
and immune parameters are only cited in this review if
such time-course measurements were performed. How-
ever, one limiting factor remains: the blood only contains
2–3% of all leucocytes. Hence, it is questionable whether
changes in leukocyte counts in the blood faithfully mim-
ic fu nctiona l processes at sin gle cel l le vel or r ather chang-
es in leukocy te distribution. In order to investigate wheth-
er a defined immune cell population is functionally al-
tered by sleep, it would be necessary to analyze the
function of purified immune cell populations or, as an
example, the measurement of function on single cell lev-
el in non-separated leukocytes in sleep deprivation/
restriction experiments. We have demonstrated that
purified and polyclonally stimulated T helper cells
(CD4 + CD25–) proliferate more and that the rhythmic
activity of regulatory T cells, which suppress detrimental
immune responses, was only observed in the condition of
normal sleep compared to sleep deprivation
[13] , whereas
cytokine secretion by T cells follows a circadian rhythm,
which was not altered by sleep [Bollinger T. , unpublished
work]. Figure 1 shows that the circadian rhythms of pro-
lactin and T cell proliferation are significantly inf luenced
by sleep, whereas the circadian rhythms of IL-2 and cor-
tisol are not. Additionally, in human experiments with
sleep restriction for several days, it has been shown that
proinflammatory substances like IL-6 and TNF- are in-
creased
[12] . Hence, sleep seems to be an important regu-
lator of immunological homeostasis.
Most of the above-mentioned studies demonstrated
circadian rhythms in the analyzed immune parameters
which were modified by sleep. The overall finding is that
sleep improves immune responses and that most immune
cells, with the exception of NK cells, have their peak pro-
inflammatory activity at night. Therefore, in order to un-
derstand the influence of sleep on immune responses, it is
essential to understand the basis of circadian rhythms of
imm une f un ct ions . Mo re ove r, t o d isti ng ui sh be twee n sys -
temically driven (e.g. circadian rhythms of hormones)
and cellular rhythms (cellular circadian clock), future
studies should address the analysis of circadian and sleep-
dependent immune functions in distinct and purified cell
populations or at the single cell level.
Interestingly, immunological changes seen in sleep
loss and those observed in aged humans bear several sim-
ilarities, such as attenuated T cell immunity, increased
innate immune activation, and reduced adaptive im-
mune responses after vaccination
[25] . Furthermore, it is
known that the circadian timing system (explained later)
changes with age, resulting in phase advances of the
sleep-wake cycle and attenuated rhythms of hormones
10
20
Cortisol (µg/dl)
20:00
a8:00 20:00
300
600
IL-2 (pg/ml)
20:00
c8:00 20:00
10
20
Prolactin (ng/ml)
20:00
b8:00 20:00
25
75
T cell
proliferation (%)
20:00
d8:00 20:00
50
Fig. 1. Influence of sleep on rhythmic hor-
monal and immune parameters. Periph-
eral blood wa s drawn from 7 hea lthy young
men who either slept normally (solid line)
or were sleep deprived for 1 day (dashed
line). Average circadian serum profiles of
cortisol (
a ) and prolactin ( b ) under both
conditions are shown. The secretion of IL-
2 (
c ) and the proliferation ( d ) of polyclon-
ally stimulated CD4 + CD25 T cells is de-
picted (modified from Bollinger et al.
[13] ).
Bollinger /Bollinger /Oster /Solbach
Gerontology
4
such as cortisol and growth hormone [25] . Even though
there is no mechanistic link between the immunological
changes brought about by sleep loss or aging, it seems re-
markable that both processes deregulate circadian tim-
ing and circadian endocrine rhythms. Therefore, the
principles of the proposed model might also be true for
at least some of the age-related changes of the immune
system.
Circadian Clock and Immune Responses
Circadian rhythms a re an external manifestation of an
internal clock that measures daytime
[26] . Circadian
clocks are found in most species and allow the organism
to anticipate reoccurring daily variations in environmen-
tal conditions. They regulate a wide range of biological
functions from behavior (such as the sleep/wake cycle
[27–30] ) down to molecular processes including chroma-
tin modifications and DNA repair. The latter and the cir-
cadian influence on immune function are important fac-
tors in the regulation of cellular homeostasis and, hence,
of development and aging
[26] . Mutations in clock genes
can lead to sleep disorders
[27] . Hence, the circadian
clock, together with a homeostatic component of un-
known origin, directly regulates sleep/wake patterns a nd,
therefore, sleep can be seen as an integral manifestation
of the circadian timing system.
In mammals, a master circadian pacemaker is located
in the hypothalamic suprachiasmatic nuclei (SCN). The
SCN synchronizes semi-autonomous peripheral clocks
found in most central and peripheral tissues
[28] with the
external light/dark cycle. The means of this synchroniza-
tion are not yet fully understood, but likely involve SCN
regulation of hormone release (e.g. melatonin, glucocor-
ticoids), body temperature rhythms
[29, 30] , and signal-
ing via the autonomic nervous system
[30] . Conversely,
behavioral and physiological signals may feedback to the
brain and ultimately the SCN, resetting clock phase by
so-called non-phot ic cues
[28] . At the molecular level, cir-
cadian clocks are based on cellular oscillators built from
a set of interlocked transcriptional/translational autoreg-
ulatory feedback loops in which the protein products of
particular clock genes negatively feedback on their own
transcription, resulting in mRNA and protein rhythms
with a period length of approximately 24 h
[26] ( fig. 2 ).
Hundreds of clock-controlled genes that are regulated in
a similar fashion, but have no feedback function, trans-
late time information into a physiologically meaningful
signal
[28] .
Interestingly, it has been demonstrated that rat NK
cells, mouse macrophages, and human leukocytes show
rhyth mic expression of c loc k ge nes , w ith t he l atter sho wn
to be associated wit h sleep-wake patterns
[31–33] . In rats,
NK-cell inhibition of the clock gene Per2 (Period2, nega-
tive limb; fig. 2 ) leads to a decrease in expression of the
immune effectors granzyme-B and perforin, whereas in-
hibition of the clock gene Bmal1 ( Arntl , positive limb;
fig. 2 ) has t he opposite effect
[32] . Surprisingly, the knock-
down of Per2 in NK cells only marginally alters the
rhythm of interferon- (IFN- ), an important cytokine
for the cellular adaptive immune response. In contrast, in
Per2 -deficient mice, the rhythm of IFN- is severely
blunted
[34] , indicating that the rhythmic expression of
IFN- might be driven by systemic circadian signals such
as hormones or core body temperature. The fact that
D-box CCGs
DBP
E4BP4
CLOCK (NPAS2)
BMAL1
E-box CCGs
REV-ERB
ROR
RORE CCGs
PER1-3
CRY1/2
Fig. 2. Molecular model of the circadian clock. Cellular oscilla-
tions of circadian clocks are driven by a set of transcriptional/
translational feedback loops. At the positive limb, CLOCK (or in
some tissues: NPAS2) and BMAL1 activate transcription of Per
and Cry genes. PER/CRY protein complexes negatively feedback
on CLOCK/BMAL1 (negative limb). This core oscillator is stabi-
lized by ancillary loops including Rev-erb
/Rora and E4bp4 / Dbp .
Timing signals from core and ancillary loops are translated into
physiological signals via transcriptional regulation of clock-con-
trolled genes (CCGs) via E-box, D-box and RORE promoter ele-
ments. Dashed lines = Inhibitory sig nals; gray arrows = activating
signals. This model of the circadian clock was modified from
Hastings et al.
[42] .
Sleep, Immunity, and Circadian Clocks Gerontology
5
rhythmically secreted hormones, e.g. glucocorticoids or
melatonin, or autonomic activation can modulate im-
mune functions has been previously demonstrated
[35
38] . Per2 mutant mice respond less severely to lipopoly-
saccharide-induced septic shock than wild-type animals
[39] . Furthermore, deletion of Bmal1 causes impaired B
cell development
[40] . Together, these data strongly indi-
cate that circadian clocks are key regulators of immune
functions. Because of the tight entanglement of circadian
rhythms, sleep, and the mutual effect of both factors on
immunity, it seems likely that the 3 processes are caus-
ally linked and interact with each other.
Hypothesis: Circadian Clocks – Master Regulators of
Immune Rhythms
The circadian rhythm of immune responses is driven
by the interplay of master (SCN) and peripheral clocks
(immune cells). The SCN drives the release of rhythmic
soluble factors (hormones) which affect immune cell
function (hormonal priming) as well as the circadian
clock of immune cells [Bollinger T., unpublished work].
Furthermore, the SCN may affect immune cells through
the sympathetic nervous system as well as core body tem-
perature. We suggest a model ( fig. 3 ) in which factors re-
leased in relationship to the circadian rhyt hm – which are
(e.g. prolactin, growth hormone) or are not (e.g. cortisol
and melatonin) modulated by sleep – regulate the hor-
monal priming of immune cells and subsequently their
immune function. Furthermore, we predict that such fac-
tors, the sympathetic nervous system, and core body tem-
perature synchronize the peripheral circadian clocks of
immune cells and thereby drive the functional rhythm of
immunity at the cellular level. Conversely, immune cells
are able to modulate sleep and circadian clocks
[8, 41] .
Our model predicts that immune cells would be able to
sustain a rhythm, but need signals from the master clock
(SCN) in order to stay synchronized to other peripheral
clocks and to maintain clock synchrony within the leu-
kocyte subpopulations. We further predict that immune
cell cultures would gradually lose their synchrony in vi-
tro due to the lack of such synchronizing factors. Adding
these synchronizing factors should re-synchronize these
cultures in a similar way to what has been shown for fi-
broblasts and other cell lines
[29] . Since the circadian
clock is redundantly stabilized, short-term sleep depriva-
tion/restriction will have only minor effects on leukocyte
clock synchrony, but it will affect the circadian immune
rhythm through sleep-modulated circadian signals such
as prolactin and growth hormone (hormonal priming of
immune cells). Furthermore, we speculate that long-term
sleep deprivation/restriction will disrupt the synchrony
amongst different leukocyte clocks, leading to a desyn-
chronization of immune functions and, ultimately, de-
regulated immune responses. Clock desynchrony has al-
ready been shown to be detrimental for metabolic ho-
meostasis, for example
[42] . If our assumption is right,
then the effects of acute sleep loss on circadian immune
rhythms should be reversible through the mimicry of cir-
cadian rhythms of prolactin and growth hormone serum
levels, e.g. by timed infusion of these hormones. The dis-
ruption of circadian synchrony by long-term sleep depri-
vation/restriction can most likely be experimentally
amended by enforcing a normal sleep/wake cycle or by
timed exposure to circadian synchronizers such as light.
A good model to monitor clock changes at tissue levels
are circadian clock reporter mice
[43] . We speculate that
clock desynchrony in the leukocyte subpopulations due
Sleep
Master clock
(SCN)
Peripheral clocks
(immune cells)
Immune
function
Cytokines ?
Neurotransmission
melatonin
Soluble factors
(cortisol)
Soluble factors
(cortisol)
Soluble factors
(prolactin, GH)
CCGs
Cytokines (IL-1 , TNF- )␤␣
Soluble factors (prolactin, GH)
?
Soluble factors
CBT, SNS
Fig. 3. Clock-sleep-immune model. The SCN is a key regulator of
sleep and synchronizes peripheral clocks all over the body, in-
cluding the cellular oscillators of immune cells. Sleep might feed-
ba ck t o t he c irc ad ian tim ing sy ste m – m ost li kel y by neu ron al and
humoral factors and by modulation of core body temperature –
thereby stabilizing the SCN as well as the periphera l clocks of im-
mune cells. Furthermore, sleep and the SCN together modulate
the function of immune cells through soluble factors (hormonal
priming). Immune cells, on the other hand, affect sleep via the
s ec re ti on of c y to ki n es , s uc h a s I L-1 , IL-6, and TNF- . The secre-
tion of cytokines might further modulate SCN and peripheral
clock rhythms. CBT = Core body temperature; SNS = sympathet-
i c n e r v e s y s t e m ; C C G s = c l o c k - c o n t r o l l e d g e n e s .
Bollinger /Bollinger /Oster /Solbach
Gerontology
6
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to chronic sleep disturbances will promote immune-re-
lated diseases such as autoimmunity, allergy, and tumors.
If this is true, then sleep-loss-induced clock desynchrony
could be seen as a learned response and, hence, represent
a form of peripheral memory of sleep loss.
In summary, it has become clear that sleep is essential
for immune homeostasis and that the deprivation/re-
striction of sleep leads to altered immune functions. Our
model proposes that the circadian timing system is the
underlying mechanism which simultaneously regulates
the sleep/wake cycle and, in consequence, the synchrony
of circadian immune rhythms and thereby immune ho-
meostasis. We speculate that long-term sleep depriva-
tion/restriction deregulates the circadian timing system
and subsequently disrupts immune homeostasis.
A c k n o w l e d g m e n t s
We thank Tanja Lange (Neuroendocrinology, University of
Luebeck) for helpful discussions. We also t hank Tim Hinch liff for
carefully reading and editing the manuscript. H.O. is an Emmy
Noether fellow of the DFG. This work was supported by a grant
of the DFG, SFB 654, projects B5 & C8.
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... We found an association between sleep duration and pancreatic cancer (HR 6 vs. 7h , 2.67; 95% CI: 1.08-6.61). A linear relationship between sleep duration and colorectal cancer was observed Chinese Medical Journal 2021;134 (24) www.cmj.org We found a U-shaped association between sleep duration and pancreatic cancer in the sensitivity analysis (HR 6vs.7h , 3.81; 95% CI: 1.30-11.16; ...
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... The large sample size permits sufficient power to assess associations with major GI cancer sites. In addition, its prospective design with a long follow-up time minimized the potential Chinese Medical Journal 2021;134 (24) www.cmj.org selection or recall bias of sleep duration, and its questionnaire design that included relevant covariates allowed us to adjust for important potential confounders during the statistical analysis. ...
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Prolonged sleep deprivation in rats causes an unexplained hypercatabolic state, secondary malnutrition symptoms, and mortality. The nature of the vital impairment has long been a mystery. Its determination would help to elucidate the type of organic dysfunction that sleep prevents. There are no gross detectable disturbances in intermediary metabolism, clinical chemistry, or hematological indexes that provide substantial clues to the mediation of sleep-deprivation effects. Furthermore, postmortem examinations reveal no systematic morphological or histopathological findings. Taken together, the cachexia and the absence of evidence of structural damage or organ dysfunction pointed to involvement of a regulatory system that was diffuse, possibly the immune system. Blood cultures revealed invasion by opportunistic microbes to which there was no febrile response. These results suggest that the life-threatening condition of prolonged sleep deprivation is a breakdown of host defense against indigenous and pathogenic microorganisms.
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Sleeping sickness patients are classically described as sleepy by day and restless by night. Prior to this study, we had objectively confirmed this description by recording 24-h sleep patterns in a patient with human African trypanosomiasis. We report 24-h polysomnographic recordings (EEG, electrooculogram, electromyogram, electrocardiogram, and nasal, buccal, and thoracic respiratory traces) performed on two eight-channel electroencephalographs in eight patients with untreated sleeping sickness at an early stage of meningoencephalitis. As in our previously reported patient, there was no hypersomnia. The patients presented mainly a disorganization of the circadian alternation of sleeping and waking, with no or little alteration in the states of vigilance at this early stage of the disease. The disorganization was proportional to the degree of severity of the clinical symptoms. It may be due to an alteration in biological clock mechanisms.