51
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Baglioni V, Coutinho E, Menassa DA, Giannoccaro MP, Jacobson L, Buttiglione M, Petruzzelli O, Cardona F, Vincent A. Antibodies to neuronal surface proteins in Tourette Syndrome: Lack of evidence in a European paediatric cohort. Brain Behav Immun 2019; 81:665-669. [PMID: 31425826 DOI: 10.1016/j.bbi.2019.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022] Open
Abstract
In Tourette Syndrome (TS) a role for autoantibodies directed against neuronal proteins has long been suspected, but so far results are still inconsistent. The aim of this study was to look for antibodies to specific or undefined neuronal proteins that could be involved in the aetiology of the disease. Sera from children with Tourette Syndrome or another chronic tic disorder (TS/TD), collected as part of the longitudinal European Multicenter Tics in Children Study, were investigated. Participants included 30 siblings of patients with TS/TD prior to developing tics (preclinical stage) and the same children after the first tic onset (onset), and 158 patients in the chronic phase undergoing an acute relapse (exacerbation). Presence of antibodies binding to rodent brain tissue was assessed by immunohistology on rat brain sections and by immunofluorescent staining of live hippocampal neurons. Live cell-based assays were used to screen for antibodies to NMDAR, CASPR2, LGI1, AMPAR and GABAAR. Immunohistology indicated evidence of antibodies reactive with brain tissue, binding mainly to the hippocampus, the basal ganglia or the cerebellum in 26/218 (12%), with 8% of the preclinical or onset sera binding to the dentate gyrus/CA3 region or cerebellum. Only two individuals (one pre-clinical, one chronic) had antibodies binding the NMDAR and the binding was only weakly positive. No other specific antibodies were detected. Despite some immunoreactivity towards neuronal antigens on brain tissue, this was not mirrored by antibodies binding to live neurons, suggesting the presence of non-specific antibodies or those that bind non-pathogenic intracellular epitopes. NMDAR or the other neuronal surface antibodies tested were very infrequent in these patients. The evidence for pathogenic antibodies that could be causative of TS is weak.
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Affiliation(s)
- V Baglioni
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK; Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - E Coutinho
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - D A Menassa
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - M P Giannoccaro
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - L Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - M Buttiglione
- Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - O Petruzzelli
- Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - F Cardona
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - A Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
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52
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Ajmone-Cat MA, Spinello C, Valenti D, Franchi F, Macrì S, Vacca RA, Laviola G. Brain-Immune Alterations and Mitochondrial Dysfunctions in a Mouse Model of Paediatric Autoimmune Disorder Associated with Streptococcus: Exacerbation by Chronic Psychosocial Stress. J Clin Med 2019; 8:jcm8101514. [PMID: 31547098 PMCID: PMC6833026 DOI: 10.3390/jcm8101514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 09/17/2019] [Accepted: 09/18/2019] [Indexed: 12/18/2022] Open
Abstract
Adverse psychosocial experiences have been shown to modulate individual responses to immune challenges and affect mitochondrial functions. The aim of this study was to investigate inflammation and immune responses as well as mitochondrial bioenergetics in an experimental model of Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS). Starting in adolescence (postnatal day 28), male SJL/J mice were exposed to five injections (interspaced by two weeks) with Group-A beta-haemolytic streptococcus (GAS) homogenate. Mice were exposed to chronic psychosocial stress, in the form of protracted visual exposure to an aggressive conspecific, for four weeks. Our results indicate that psychosocial stress exacerbated individual response to GAS administrations whereby mice exposed to both treatments exhibited altered cytokine and immune-related enzyme expression in the hippocampus and hypothalamus. Additionally, they showed impaired mitochondrial respiratory chain complexes IV and V, and reduced adenosine triphosphate (ATP) production by mitochondria and ATP content. These brain abnormalities, observed in GAS-Stress mice, were associated with blunted titers of plasma corticosterone. Present data support the hypothesis that challenging environmental conditions, in terms of chronic psychosocial stress, may exacerbate the long-term consequences of exposure to GAS processes through the promotion of central immunomodulatory and oxidative stress.
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Affiliation(s)
- Maria Antonietta Ajmone-Cat
- National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Rome, Italy.
| | - Chiara Spinello
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Rome, Italy.
- Department of Mechanical and Aerospace Engineering, New York University Tandon School of Engineering, Brooklyn, NY 11201, USA.
| | - Daniela Valenti
- Institute of Biomembranes, Bioenergetics and Molecular Biotechnologies, National Council of Research, Via Giovanni Amendola 122/O - 70126 Bari, Italy.
| | - Francesca Franchi
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Rome, Italy.
| | - Simone Macrì
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Rome, Italy.
| | - Rosa Anna Vacca
- Institute of Biomembranes, Bioenergetics and Molecular Biotechnologies, National Council of Research, Via Giovanni Amendola 122/O - 70126 Bari, Italy.
| | - Giovanni Laviola
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Rome, Italy.
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53
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Gerentes M, Pelissolo A, Rajagopal K, Tamouza R, Hamdani N. Obsessive-Compulsive Disorder: Autoimmunity and Neuroinflammation. Curr Psychiatry Rep 2019; 21:78. [PMID: 31367805 DOI: 10.1007/s11920-019-1062-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Here, we propose to review the immuno-inflammatory hypothesis in OCD given the concurrent incidence of autoimmune comorbidities, infectious stigma, and raised levels of inflammatory markers in a significant subset of patients. A better understanding of the immune dysfunction in OCD may allow stratifying the patients in order to design personalized pharmaco/psychotherapeutic strategies. RECENT FINDINGS A persistent low-grade inflammation involving both innate and adaptive immune system with coexisting autoimmune morbidities and stigma of infectious events has been prominently observed in OCD. Hence, specific treatments targeting inflammation/infection are a feasible alternative in OCD. This review highlights that OCD is associated with low-grade inflammation, neural antibodies, and neuro-inflammatory and auto-immune disorders. In some subset of OCD patients, autoimmunity is likely triggered by specific bacterial, viral, or parasitic agents with overlapping surface epitopes in CNS. Hence, subset-profiling in OCD is warranted to benefit from distinct immune-targeted treatment modalities.
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Affiliation(s)
- Mona Gerentes
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Antoine Pelissolo
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.,Faculté de médecine, UPEC, Université Paris-Est, 94000, Créteil, France
| | | | - Ryad Tamouza
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Nora Hamdani
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France. .,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.
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54
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Cunningham MW. Molecular Mimicry, Autoimmunity, and Infection: The Cross-Reactive Antigens of Group A Streptococci and their Sequelae. Microbiol Spectr 2019; 7:10.1128/microbiolspec.gpp3-0045-2018. [PMID: 31373269 PMCID: PMC6684244 DOI: 10.1128/microbiolspec.gpp3-0045-2018] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Indexed: 12/20/2022] Open
Abstract
The group A streptococci are associated with a group of diseases affecting the heart, brain, and joints that are collectively referred to as acute rheumatic fever. The streptococcal immune-mediated sequelae, including acute rheumatic fever, are due to antibody and cellular immune responses that target antigens in the heart and brain as well as the group A streptococcal cross-reactive antigens as reviewed in this article. The pathogenesis of acute rheumatic fever, rheumatic heart disease, Sydenham chorea, and other autoimmune sequelae is related to autoantibodies that are characteristic of autoimmune diseases and result from the immune responses against group A streptococcal infection by the host. The sharing of host and streptococcal epitopes leads to molecular mimicry between the streptococcal and host antigens that are recognized by the autoantibodies during the host response. This article elaborates on the discoveries that led to a better understanding of the pathogenesis of disease and provides an overview of the history and the most current thought about the immune responses against the host and streptococcal cross-reactive antigens in group A streptococcal sequelae.
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Affiliation(s)
- Madeleine W Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
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55
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A Pediatric Infectious Disease Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated With Streptococcal Infection and Pediatric Acute-onset Neuropsychiatric Syndrome. Pediatr Infect Dis J 2019; 38:706-709. [PMID: 30747831 DOI: 10.1097/inf.0000000000002295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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56
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Gata-Garcia A, Diamond B. Maternal Antibody and ASD: Clinical Data and Animal Models. Front Immunol 2019; 10:1129. [PMID: 31191521 PMCID: PMC6547809 DOI: 10.3389/fimmu.2019.01129] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/03/2019] [Indexed: 12/26/2022] Open
Abstract
Over the past several decades there has been an increasing interest in the role of environmental factors in the etiology of neuropsychiatric and neurodevelopmental disorders. Epidemiologic studies have shifted from an exclusive focus on the identification of genetic risk alleles for such disorders to recognizing and understanding the contribution of xenobiotic exposures, infections, and the maternal immune system during the prenatal and early post-natal periods. In this review we discuss the growing literature regarding the effects of maternal brain-reactive antibodies on fetal brain development and their contribution to the development of neuropsychiatric and neurodevelopmental disorders. Autoimmune diseases primarily affect women and are more prevalent in mothers of children with neurodevelopmental disorders. For example, mothers of children with Autism Spectrum Disorder (ASD) are significantly more likely to have an autoimmune disease than women of neurotypically developing children. Moreover, they are four to five times more likely to harbor brain-reactive antibodies than unselected women of childbearing age. Many of these women exhibit no apparent clinical consequence of harboring these antibodies, presumably because the antibodies never access brain tissue. Nevertheless, these maternal brain-reactive antibodies can access the fetal brain, and some may be capable of altering brain development when present during pregnancy. Several animal models have provided evidence that in utero exposure to maternal brain-reactive antibodies can permanently alter brain anatomy and cause persistent behavioral or cognitive phenotypes. Although this evidence supports a contribution of maternal brain-reactive antibodies to neurodevelopmental disorders, an interplay between antibodies, genetics, and other environmental factors is likely to determine the specific neurodevelopmental phenotypes and their severity. Additional modulating factors likely also include the microbiome, sex chromosomes, and gonadal hormones. These interactions may help to explain the sex-bias observed in neurodevelopmental disorders. Studies on this topic provide a unique opportunity to learn how to identify and protect at risk pregnancies while also deciphering critical pathways in neurodevelopment.
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Affiliation(s)
- Adriana Gata-Garcia
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institute for Medical Research, Manhasset, NY, United States.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Betty Diamond
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institute for Medical Research, Manhasset, NY, United States
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57
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Sikder S, Rush CM, Govan BL, Norton RE, Cunningham MW, McMillan DJ, Sriprakash KS, Ketheesan N. Reply to Dale and Shulman. J Infect Dis 2019; 219:675-676. [PMID: 30247617 DOI: 10.1093/infdis/jiy561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/20/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Suchandan Sikder
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Catherine M Rush
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Brenda L Govan
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | | | - Madeleine W Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - David J McMillan
- Inflammation and Healing Biomedical Research Cluster, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, Australia
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58
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Toor D, Sharma N. T cell subsets: an integral component in pathogenesis of rheumatic heart disease. Immunol Res 2019; 66:18-30. [PMID: 29170852 DOI: 10.1007/s12026-017-8978-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Acute rheumatic fever (ARF) is a consequence of pharyngeal infection of group A streptococcal (GAS) infection. Carditis is the most common manifestation of ARF which occurs in 30-45% of the susceptible individuals. Overlooked ARF cases might further progress towards rheumatic heart disease (RHD) in susceptible individuals, which ultimately leads to permanent heart valve damage. Molecular mimicry between streptococcal antigens and human proteins is the most widely accepted theory to describe the pathogenesis of RHD. In the recent past, various subsets of T cells have been reported to play an imperative role in the pathogenesis of RHD. Alterations in various T cell subsets, viz. Th1, Th2, Th17, and Treg cells, and their signature cytokines influence the immune responses and are associated with pathogenesis of RHD. Association of other T cell subsets (Th3, Th9, Th22, and TFH) is not defined in context of RHD. Several investigations have confirmed the up-regulation of adhesion molecules and thus infiltration of T cells into the heart tissues. T cells secrete both Th type 1 and type 2 cytokines and these auto-reactive T cells play a key role in progression of heart valve damage. In this review, we are going to discuss about the role of T cell subsets and their corresponding cytokines in the pathogenesis of RHD.
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Affiliation(s)
- Devinder Toor
- Amity Institute of Virology and Immunology, Amity University Uttar Pradesh, Sector-125, Noida, Uttar Pradesh, 201313, India.
| | - Neha Sharma
- Amity Institute of Virology and Immunology, Amity University Uttar Pradesh, Sector-125, Noida, Uttar Pradesh, 201313, India
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59
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Fominykh VV, Frei EA, Brylev LV, Gulyaeva NV. Autoimmune Encephalitis: A Disease of the 21st Century at the Crossroads of Neurology and Psychiatry. NEUROCHEM J+ 2018. [DOI: 10.1134/s1819712418040037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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60
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Lamothe H, Baleyte JM, Smith P, Pelissolo A, Mallet L. Individualized Immunological Data for Precise Classification of OCD Patients. Brain Sci 2018; 8:E149. [PMID: 30096863 PMCID: PMC6119917 DOI: 10.3390/brainsci8080149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Pauline Smith
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
| | - Antoine Pelissolo
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- INSERM, U955, Team 15, 94000 Créteil, France.
| | - Luc Mallet
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, 1202 Geneva, Switzerland.
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61
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A Pediatric Neurology Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute-Onset Neuropsychiatric Syndrome. J Pediatr 2018; 199:243-251. [PMID: 29793872 DOI: 10.1016/j.jpeds.2018.04.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/25/2018] [Accepted: 04/17/2018] [Indexed: 12/21/2022]
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62
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Paediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Beta-Haemolytic Streptococcal Infection: An Indication for Tonsillectomy? A Review of the Literature. Int J Otolaryngol 2018; 2018:2681304. [PMID: 29675045 PMCID: PMC5841079 DOI: 10.1155/2018/2681304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 11/20/2017] [Accepted: 12/03/2017] [Indexed: 12/03/2022] Open
Abstract
Background. Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS) is the acute onset of neuropsychiatric symptoms following group A beta-haemolytic streptococcal infection. The aetiology remains elusive. However, with group A streptococcus being the most common bacterial cause of tonsillitis, surgical intervention in the form of tonsillectomy has often been considered as a potential therapy. Methods. A MEDLINE® search was undertaken using keywords “PANDAS” or “paediatric autoimmune neuropsychiatric disorders associated with streptococcus” combined with “tonsillectomy”. Results. Six case reports and 3 case series met the inclusion criteria. Demesh et al. (case series) reported a dramatic reduction in neuropsychiatric symptom severity in the patient cohort undergoing tonsillectomy. Two case series suggest that there is no association between tonsillectomy and resolution of PANDAS. Conclusion. Due to the lack of uniform data and sporadic reports, tonsillectomy should be carefully adopted for the treatment of this disorder. In particular, tonsillectomies/adenoidectomies to alleviate neuropsychiatric symptoms should be avoided until more definitive evidence is at our disposal. This review highlights the importance of a potential collaborative prospective study.
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63
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Frick L, Rapanelli M, Jindachomthong K, Grant P, Leckman JF, Swedo S, Williams K, Pittenger C. Differential binding of antibodies in PANDAS patients to cholinergic interneurons in the striatum. Brain Behav Immun 2018; 69:304-311. [PMID: 29233751 PMCID: PMC5857467 DOI: 10.1016/j.bbi.2017.12.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/07/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022] Open
Abstract
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, or PANDAS, is a syndrome of acute childhood onset of obsessive-compulsive disorder and other neuropsychiatric symptoms in the aftermath of an infection with Group A beta-hemolytic Streptococcus (GABHS). Its pathophysiology remains unclear. PANDAS has been proposed to result from cross-reactivity of antibodies raised against GABHS with brain antigens, but the targets of these antibodies are unclear and may be heterogeneous. We developed an in vivo assay in mice to characterize the cellular targets of antibodies in serum from individuals with PANDAS. We focus on striatal interneurons, which have been implicated in the pathogenesis of tic disorders. Sera from children with well-characterized PANDAS (n = 5) from a previously described clinical trial (NCT01281969), and matched controls, were infused into the striatum of mice; antibody binding to interneurons was characterized using immunofluorescence and confocal microscopy. Antibodies from children with PANDAS bound to ∼80% of cholinergic interneurons, significantly higher than the <50% binding seen with matched healthy controls. There was no elevated binding to two different populations of GABAergic interneurons (PV and nNOS-positive), confirming the specificity of this phenomenon. Elevated binding to cholinergic interneurons resolved in parallel with symptom improvement after treatment with intravenous immunoglobulin. Antibody-mediated dysregulation of striatal cholinergic interneurons may be a locus of pathology in PANDAS. Future clarification of the functional consequences of this specific binding may identify new opportunities for intervention in children with this condition.
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Affiliation(s)
| | | | | | - Paul Grant
- Pediatrics and Developmental Neuroscience Branch, National Institute
of Mental Health
| | - James F. Leckman
- Department of Psychology, Yale University,Child Study Center, Yale University
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute
of Mental Health
| | - Kyle Williams
- Department of Psychiatry, Yale University, United States; Child Study Center, Yale University, United States; Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, United States.
| | - Christopher Pittenger
- Department of Psychiatry, Yale University, United States; Department of Psychology, Yale University, United States; Child Study Center, Yale University, United States; Interdepartmental Neuroscience Program, Yale University, United States.
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64
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Zibordi F, Zorzi G, Carecchio M, Nardocci N. CANS: Childhood acute neuropsychiatric syndromes. Eur J Paediatr Neurol 2018; 22:316-320. [PMID: 29398245 DOI: 10.1016/j.ejpn.2018.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 12/06/2017] [Accepted: 01/08/2018] [Indexed: 11/25/2022]
Abstract
The terms Pediatric Autoimmune Neuropsychiatric disorders associated with streptococcal infections (PANDAS), Pediatric acute-onset neuropsychiatric Syndrome (PANS), and Childhood Acute Neuropsychiatric Symptoms (CANS) have been used to describe certain acute onset neuropsychiatric pediatric disorders. This clinical characteristic was unusually abrupt onset of obsessive compulsive symptoms and/or severe eating restrictions and concomitant cognitive, behavioral or neurological symptoms. Because the CANS/PANS criteria define a broad spectrum of neuropsychiatric conditions, the syndrome is presumed to result from a variety of disease mechanisms and to have multiple etiologies, ranging from postinfectious autoimmune and neuroinflammatory disorders to toxic, endocrine or metabolic disorders. We suggest a diagnostic flow-chart in case of acute onset neuropsychiatric syndrome to better define diagnostic criteria, identify possible subtypes and delineate treatment.
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Affiliation(s)
- Federica Zibordi
- Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Giovanna Zorzi
- Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Miryam Carecchio
- Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Nardo Nardocci
- Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy.
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65
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Brown KD, Farmer C, Freeman GM, Spartz EJ, Farhadian B, Thienemann M, Frankovich J. Effect of Early and Prophylactic Nonsteroidal Anti-Inflammatory Drugs on Flare Duration in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Observational Study of Patients Followed by an Academic Community-Based Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic. J Child Adolesc Psychopharmacol 2017; 27:619-628. [PMID: 28696786 PMCID: PMC5749580 DOI: 10.1089/cap.2016.0193] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the sudden onset of severe obsessive-compulsive symptoms and/or eating restriction along with at least two coinciding neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. We evaluated the impact of nonsteroidal anti-inflammatory drug (NSAID) treatment on flare duration in PANS/PANDAS. METHODS Patient inclusion criteria: Patients were included if they had at least one neuropsychiatric deterioration ("flare") that met strict PANS/PANDAS research criteria and for which flare duration could be assessed. Flare inclusion criteria: Any flare that started before October 15, 2016 was included and followed until the flare resolved or until the end of our data collection (November 1, 2016). Flare exclusion criteria: Flares were excluded if they were incompletely resolved, treated with aggressive immunomodulation, or treated with NSAIDs late (>30 days of flare onset). Ninety-five patients met study inclusion criteria and collectively experienced 390 flares that met flare criteria. Data were analyzed using multilevel linear models, adjusting for demographics, disease, and treatment covariates. RESULTS NSAID use was associated with a significantly shorter flare duration. Flares not treated with NSAIDs had a mean duration of approximately 12.2 weeks (95% CI: 9.3-15.1). Flares that occurred while the child was on NSAID maintenance therapy were approximately 4 weeks shorter than flares not managed with NSAIDs (95% CI: 1.85-6.24; p < 0.0001). Flares treated with NSAIDs within 30 days of flare onset were approximately 2.6 weeks shorter than flares not managed with NSAIDs (95% CI: 0.43-4.68; p = 0.02). Flares treated prophylactically and those treated early with NSAIDs did not differ in duration (p = 0.26). Among the flares that received NSAID treatment within the first 30 days, earlier intervention was modestly associated with shorter flare durations (i.e., for each day that NSAID treatment was delayed, flare duration increased by 0.18 weeks; 95% CI: 0.03-0.33; p = 0.02), though it was not statistically significant after controlling for covariates (p = 0.06). CONCLUSION NSAIDs given prophylactically or within 30 days of flare onset may shorten neuropsychiatric symptom duration in patients with new-onset and relapsing/remitting PANS and PANDAS. A randomized placebo-control clinical trial of NSAIDs in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla D. Brown
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - G. Mark Freeman
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Ellen J. Spartz
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Child & Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Frankovich J, Swedo S, Murphy T, Dale RC, Agalliu D, Williams K, Daines M, Hornig M, Chugani H, Sanger T, Muscal E, Pasternack M, Cooperstock M, Gans H, Zhang Y, Cunningham M, Bernstein G, Bromberg R, Willett T, Brown K, Farhadian B, Chang K, Geller D, Hernandez J, Sherr J, Shaw R, Latimer E, Leckman J, Thienemann M, PANS/PANDAS Consortium. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II-Use of Immunomodulatory Therapies. J Child Adolesc Psychopharmacol 2017; 27:574-593. [PMID: 36358107 PMCID: PMC9836706 DOI: 10.1089/cap.2016.0148] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinically heterogeneous disorder with a number of different etiologies and disease mechanisms. Inflammatory and postinfectious autoimmune presentations of PANS occur frequently, with some clinical series documenting immune abnormalities in 75%-80% of patients. Thus, comprehensive treatment protocols must include immunological interventions, but their use should be reserved only for PANS cases in which the symptoms represent underlying neuroinflammation or postinfectious autoimmunity, as seen in the PANDAS subgroup (Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections). Methods: The PANS Research Consortium (PRC) immunomodulatory task force is comprised of immunologists, rheumatologists, neurologists, infectious disease experts, general pediatricians, psychiatrists, nurse practitioners, and basic scientists with expertise in neuroimmunology and PANS-related animal models. Preliminary treatment guidelines were created in the Spring of 2014 at the National Institute of Health and refined over the ensuing 2 years over conference calls and a shared web-based document. Seven pediatric mental health practitioners, with expertise in diagnosing and monitoring patients with PANS, were consulted to create categories in disease severity and critically review final recommendations. All authors played a role in creating these guidelines. The views of all authors were incorporated and all authors gave final approval of these guidelines. Results: Separate guidelines were created for the use of immunomodulatory therapies in PANS patients with (1) mild, (2) moderate-to-severe, and (3) extreme/life-threatening severity. For mildly impairing PANS, the most appropriate therapy may be "tincture of time" combined with cognitive behavioral therapy and other supportive therapies. If symptoms persist, nonsteroidal anti-inflammatory drugs and/or short oral corticosteroid bursts are recommended. For moderate-to-severe PANS, oral or intravenous corticosteroids may be sufficient. However, intravenous immunoglobulin (IVIG) is often the preferred treatment for these patients by most PRC members. For more severe or chronic presentations, prolonged corticosteroid courses (with taper) or repeated high-dose corticosteroids may be indicated. For PANS with extreme and life-threatening impairment, therapeutic plasma exchange is the first-line therapy given either alone or in combination with IVIG, high-dose intravenous corticosteroids, and/or rituximab. Conclusions: These recommendations will help guide the use of anti-inflammatory and immunomodulatory therapy in the treatment of PANS.
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Affiliation(s)
- Jennifer Frankovich
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Tanya Murphy
- Rothman Center for Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Russell C. Dale
- Paediatrics and Child Health, Institute for Neuroscience and Muscle Research, the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Dritan Agalliu
- Pathology and Cell Biology (in Neurology and Pharmacology), Columbia University, New York, New York
| | - Kyle Williams
- Pediatric Neuropsychiatry and Immunology Program in the OCD and Related Disorders Program, Harvard Medical School, Boston, Massachusetts
| | - Michael Daines
- Allergy, Immunology, and Rheumatology, The University of Arizona College of Medicine Tuscon, Tuscon, Arizona
| | - Mady Hornig
- Epidemiology, Center for Infection and Immunity, Columbia University Medical Center, New York, New York
| | - Harry Chugani
- Pediatric Neurology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Terence Sanger
- Neurology, University of Southern California Pediatric Movement Disorders Center, Children's Hospital of Los Angeles, Los Angeles, California
| | - Eyal Muscal
- Pediatric Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Mark Pasternack
- Pediatric Infectious Disease, Harvard Medical School, Boston, Massachusetts
| | - Michael Cooperstock
- Pediatric Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Hayley Gans
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California
| | - Yujuan Zhang
- Pediatric Rheumatology, Tufts University School of Medicine, Boston, Massachusetts
| | - Madeleine Cunningham
- Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Gail Bernstein
- Child and Adolescent Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Reuven Bromberg
- Pediatric Rheumatology, Miami Rheumatology, LLC, Miami, Florida
| | - Theresa Willett
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kayla Brown
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kiki Chang
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Daniel Geller
- Pediatric OCD and Tic Disorder Program, Harvard Medical School, Boston, Massachusetts
| | - Joseph Hernandez
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Janell Sherr
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Richard Shaw
- Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Latimer
- Pediatric Neurology, Georgetown University Hospital, Washington, District of Columbia
| | - James Leckman
- Child Psychiatry, Psychiatry, Psychology and Pediatrics, Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
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Spartz EJ, Freeman GM, Brown K, Farhadian B, Thienemann M, Frankovich J. Course of Neuropsychiatric Symptoms After Introduction and Removal of Nonsteroidal Anti-Inflammatory Drugs: A Pediatric Observational Study. J Child Adolesc Psychopharmacol 2017; 27:652-659. [PMID: 28696783 DOI: 10.1089/cap.2016.0179] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Accumulating evidence suggests that anti-inflammatory interventions can modulate neuropsychiatric symptoms. Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by an abrupt and dramatic onset of obsessive-compulsive (OC) symptoms and/or severely restrictive food intake and at least two coinciding, equally debilitating neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). Here, we describe the course of neuropsychiatric symptoms in patients diagnosed with PANS and PANDAS after introduction or removal of nonsteroidal anti-inflammatory drugs (NSAIDs). STUDY DESIGN We reviewed the electronic medical records (EMR) of 218 consecutive patients evaluated in our Stanford PANS Clinic for patients who met strict PANS or PANDAS research criteria and received NSAIDs for arthritis, pain, and/or psychiatric symptoms. We describe neuropsychiatric symptoms that were noted in the EMR before, during, and after NSAIDs were introduced or removed as the sole change in pharmacologic treatment. RESULTS Seventy-seven patients were included in the current study. Of the 52 trials in which NSAID addition was the sole change in treatment, 16 (31%) coincided with an improvement in patients' neuropsychiatric symptoms. Of the 57 trials in which removal of NSAID treatment was the sole change in treatment, 20 (35%) coincided with escalation in patients' neuropsychiatric symptoms. Thirty patients (39%) experienced side effects, mainly mild gastrointestinal symptoms, which self-resolved after removal of NSAID, reduction of dose, or change in NSAID. CONCLUSIONS Improvement in neuropsychiatric symptoms was evident in roughly one-third of NSAID treatment trials. A randomized clinical trial will be necessary to confirm whether NSAIDs are successful in reducing neuropsychiatric symptoms in youth with PANS.
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Affiliation(s)
- Ellen J Spartz
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
| | - G Mark Freeman
- 2 Pediatric Divisions of Psychiatry and Behavioral Sciences, Stanford University School of Medicine , Stanford, California
| | - Kayla Brown
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
| | - Bahare Farhadian
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
| | - Margo Thienemann
- 3 Pediatric Divisions of Child & Adolescent Psychiatry, Stanford University School of Medicine , Stanford, California
| | - Jennifer Frankovich
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
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Brown K, Farmer C, Farhadian B, Hernandez J, Thienemann M, Frankovich J. Pediatric Acute-Onset Neuropsychiatric Syndrome Response to Oral Corticosteroid Bursts: An Observational Study of Patients in an Academic Community-Based PANS Clinic. J Child Adolesc Psychopharmacol 2017; 27:629-639. [PMID: 28714753 PMCID: PMC5749576 DOI: 10.1089/cap.2016.0139] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sudden-onset severe obsessive-compulsive symptoms and/or severely restrictive food intake with at least two coinciding, similarly debilitating neuropsychiatric symptoms define Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). When associated with Group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. Most patients have a relapsing-remitting course. Treatment outcome data for youth with PANS and PANDAS are limited. METHODS One hundred seventy-eight consecutive patients were seen in the Stanford PANS clinic between September 1, 2012 and January 15, 2016, of whom 98 met PANS or PANDAS criteria, had a single episode of PANS or relapsing/remitting course, and collectively experienced 403 flares. Eighty-five flares were treated with 102 total courses of oral corticosteroids of either short (4-5 days) or long (5 days-8 weeks) duration. Response to treatment was assessed within 14 days of initiating a short burst of corticosteroids and at the end of a long burst based on clinician documentation and patient questionnaires. Data were analyzed by using multilevel random-effects models. RESULTS Patients experienced shorter flares when treated with oral corticosteroids (6.4 ± 5.0 weeks vs. 11.4 ± 8.6 weeks) than when not treated (p < 0.001), even after controlling for presumed confounding variables, including age at flare, weeks since onset of PANS illness, sex, antibiotic treatment, prophylactic antibiotics, previous immunomodulatory treatment, maintenance anti-inflammatory therapy, psychiatric medications, and cognitive behavioral therapy (p < 0.01). When corticosteroids were given for the initial PANS episode, flares tended to be shorter (10.3 ± 5.7 weeks) than when not treated (16.5 ± 9.6 weeks) (p = 0.06). This difference was statistically significant after controlling for the relevant confounding variables listed earlier (p < 0.01). Earlier use of corticosteroids was associated with shorter flare durations (p < 0.001). Longer courses of corticosteroids were associated with a more enduring impact on the duration of neuropsychiatric symptom improvement (p = 0.014). CONCLUSION Corticosteroids may be a helpful treatment intervention in patients with new-onset and relapsing/remitting PANS and PANDAS, hastening symptom improvement or resolution. When corticosteroids are given earlier in a disease flare, symptoms improve more quickly and patients achieve clinical remission sooner. Longer courses of corticosteroids may result in more durable remissions. A double-blind placebo-controlled clinical trial of corticosteroids in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla Brown
- Division of Pediatrics, Department of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Joseph Hernandez
- Division of Pediatrics, Department of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Division of Pediatrics, Department of Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part III-Treatment and Prevention of Infections. J Child Adolesc Psychopharmacol 2017; 27:594-606. [PMID: 36358106 PMCID: PMC9836684 DOI: 10.1089/cap.2016.0151] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) and its subset, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS), are emerging autoimmune encephalopathies of childhood. Management guidelines are needed. This article, from the PANS/PANDAS Consortium, presents a consensus management guideline for the infection components. Accompanying papers from the Consortium discuss psychiatric and immunomodulatory management. Methods: Literature was reviewed and integrated with the clinical experience of the authors to provide a set of practical guidelines. This article was submitted to all members of the PANS/PANDAS Consortium, and their additional comments were added. Results: The relationships between PANS and infections are reviewed. An approach to the retrospective diagnosis of group A streptococcal infection for an operational definition of PANDAS is proposed. An initial course of anti-streptococcal treatment is proposed for all newly diagnosed PANS cases. Chronic secondary antimicrobial prophylaxis is suggested for children with PANDAS who have severe neuropsychiatric symptoms or recurrent group A Streptococcus-associated exacerbations. Guidelines for children with non-streptococcal PANS include vigilance for streptococcal pharyngitis or dermatitis in the patient and close contacts. All patients with PANS or PANDAS should also be closely monitored for other intercurrent infections, including sinusitis and influenza. Intercurrent infections should be diagnosed and treated promptly according to current standard guidelines. A guideline for the assessment of infection at initial onset or during neuropsychiatric exacerbations is also presented. Standard immunizations and attention to vitamin D are encouraged. Data indicating limited utility of adenotonsillectomy and probiotics are presented. Conclusion: A working guideline for the management of infection issues in PANS and PANDAS, based on literature and expert opinion, is provided.
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Affiliation(s)
- Michael S Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Susan E Swedo
- Department of Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health (NIMH), Rockville, Maryland
| | - Mark S Pasternack
- Department of Pediatric Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
| | - Tanya K Murphy
- Director and Professor of Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida, St. Petersburg, Florida
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Affiliation(s)
- Harvey S Singer
- Professor of Neurology and Pediatric, Johns Hopkins University School of Medicine, Rubenstein Child Health Building, Baltimore, Maryland.
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Singer HS. Autoantibody-Associated Movement Disorders in Children: Proven and Proposed. Semin Pediatr Neurol 2017; 24:168-179. [PMID: 29103424 DOI: 10.1016/j.spen.2017.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Movement disorders secondary to autoantibodies in children represent a rapidly expanding group of conditions. Once considered to be limited to poststreptococcal Sydenham's chorea or rare cases of childhood systemic lupus erythematosus, a variety of antibody-related movement abnormalities are now seen as part of noninfectious autoimmune encephalitis or within an expanding list of postinfectious disorders. In this article, several proposed autoantibody-mediated movement disorders in children are reviewed. In each one, there is a hypothesized antibody biomarker that is believed to be pathogenic and cause the clinical symptoms. As will be discussed, in some, such as anti-NMDA receptor encephalitis, the strength of supporting evidence is strong. In others, antibodies have been identified, but their role as the pathophysiological mechanism remains undetermined. Lastly, there are proposed disorders, such as PANDAS, that are controversial on both a clinical and autoimmune basis.
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Affiliation(s)
- Harvey S Singer
- Departments of Neurology and Pediatrics, Johns Hopkins University, Baltimore MD.
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Dean SL, Singer HS. Treatment of Sydenham's Chorea: A Review of the Current Evidence. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:456. [PMID: 28589057 PMCID: PMC5459984 DOI: 10.7916/d8w95gj2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/09/2017] [Indexed: 12/26/2022]
Abstract
Background Sydenham’s chorea (SC), the neurologic manifestation of rheumatic fever, remains the most prevalent form of chorea in children. Suggested treatments of chorea in SC include prophylactic penicillin, symptomatic (antipsychotic and anticonvulsant) medications, and immunomodulatory therapy (steroids, intravenous immunoglobulin (IVIG), and plasma exchange). In this manuscript, we undertook a systematic review of the published literature to examine the data supporting these therapeutic recommendations. Methods A search of PubMed, Embase, Psychinfo, and clinicaltrials.gov was conducted for publications pertaining to the treatment of SC/rheumatic chorea from 1956 to 2016. Results Penicillin prophylaxis appears to reduce the likelihood of further cardiac complications and the recurrence rate of chorea. Data on symptomatic therapy for chorea are limited to individual case reports or series and rare comparison studies. The efficacy of steroid use is supported by a single placebo-controlled study and several case series. Information on other immunomodulatory therapies such as IVIG and plasmapheresis are limited to a small number of reports and a single comparison study. Discussion Treatment decisions in SC are currently based on the treating physician’s clinical experience, the desire to avoid side effects, and the existence of only limited scientific evidence. Based on a review of the available literature, chorea often improves with symptomatic therapy and immunotherapy tends to be reserved for those who fail to respond. Steroids are beneficial; however, data using IVIG and plasmapheresis are very limited. Larger, well-controlled studies, using standardized assessment scales, are required if therapeutic decisions for SC are to be based on meaningful information.
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Affiliation(s)
- Shannon L Dean
- Department of Child Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Harvey S Singer
- Department of Child Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
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Chiarello F, Spitoni S, Hollander E, Matucci Cerinic M, Pallanti S. An expert opinion on PANDAS/PANS: highlights and controversies. Int J Psychiatry Clin Pract 2017; 21:91-98. [PMID: 28498087 DOI: 10.1080/13651501.2017.1285941] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES 'Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections' (PANDAS) identified a unique subgroup of patients with abrupt onset of obsessive compulsive disorder (OCD) symptoms clinically related to Streptococcus infection and accompanied by neuropsychological and motor symptoms. After almost 20 years, PANDAS has not been accepted as distinct disorder and new criteria for paediatric acute-onset neuropsychiatric syndrome (PANS) have been replaced it, highlighting the fact that several agents rather than only Streptococcus might be involved. METHODS Extensive review of the PANDAS/PANS literature was performed on PubMed. RESULTS Although antibiotics have been reported to be effective for acute and prophylactic phases in several uncontrolled studies and non-steroidal anti-inflammatory drugs (NSAID) are used during exacerbations, clinical multicenter trials are still missing. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT) are still the first line of recommendation for acute onset OCD spectrum. Immunological therapies should be restricted to a few cases. CONCLUSIONS While PANDAS has found no confirmation as a distinct syndrome, and it is not presented in DSM-5, patients with acute onset OCD spectrum, neurocognitive and motor symptoms should be evaluated for inflammatory, infective, immunological and metabolic abnormalities with a comprehensive diagnostic algorithm.
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Affiliation(s)
| | - Silvia Spitoni
- a Department of Neurofarba , University of Florence , Florence , Italy
| | - Eric Hollander
- b Department of Psychiatry , Icahn School of Medicine , NY , USA.,c Department of Psychiatry and Behavioral Sciences , Albert Einstein College of Medicine , NY , USA
| | - Marco Matucci Cerinic
- d Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Stefano Pallanti
- a Department of Neurofarba , University of Florence , Florence , Italy.,e Institute of Neuroscience , Florence , Italy
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Jaspers-Fayer F, Han SHJ, Chan E, McKenney K, Simpson A, Boyle A, Ellwyn R, Stewart SE. Prevalence of Acute-Onset Subtypes in Pediatric Obsessive-Compulsive Disorder. J Child Adolesc Psychopharmacol 2017; 27:332-341. [PMID: 28121463 DOI: 10.1089/cap.2016.0031] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pediatric obsessive-compulsive disorder (OCD) is a common, debilitating illness. When childhood OCD symptom onset is described as acute and severe, diagnostic criteria for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) should be considered. However, the frequency and differentiating features of these putative syndromes within pediatric OCD remain poorly understood. OBJECTIVES To determine the prevalence and characteristics of those meeting PANDAS and/or PANS criteria within pediatric OCD, as determined by parent report and clinician interview. METHODS Consecutive youth presenting to a subspecialty pediatric OCD clinic were rigorously assessed through the Anxiety Disorders Interview Schedule for DSM-IV, the Children's Yale-Brown Obsessive-Compulsive Scale, and through self- and parent-report measures, including a medical questionnaire. Strict diagnostic criteria for PANDAS and PANS were applied to determine prevalence rates, and comparative analyses were performed between subgroups. RESULTS Among 136 youth with a lifetime OCD diagnosis, 5% (n = 7; 95% adjusted Wald interval: 1%-10%) met proposed criteria for PANDAS and/or PANS, of whom two met PANDAS criteria, four met PANS criteria, and one met criteria for both. Those in the PANDAS/PANS subgroup were more likely to have autoimmune illness, less likely to report symmetry factor symptoms, and had greater OCD-related family impairment during their worst OCD episode. CONCLUSION A small yet significant percentage of pediatric OCD outpatients met criteria for PANDAS and/or PANS, justifying routine screening and attention to related characteristics during assessment and management. Longitudinal studies of these putative subtypes are warranted.
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Affiliation(s)
- Fern Jaspers-Fayer
- 1 BC Children's Hospital Research Institute , Vancouver, British Columbia, Canada .,2 Department of Psychiatry, Faculty of Medicine, University of British Columbia , Vancouver, British Columbia, Canada
| | | | - Elaine Chan
- 1 BC Children's Hospital Research Institute , Vancouver, British Columbia, Canada
| | - Katherine McKenney
- 4 Department of Psychology, BC Children's Hospital , Vancouver, British Columbia, Canada
| | - Annie Simpson
- 4 Department of Psychology, BC Children's Hospital , Vancouver, British Columbia, Canada
| | - Andrea Boyle
- 4 Department of Psychology, BC Children's Hospital , Vancouver, British Columbia, Canada
| | - Rhonda Ellwyn
- 1 BC Children's Hospital Research Institute , Vancouver, British Columbia, Canada
| | - S Evelyn Stewart
- 1 BC Children's Hospital Research Institute , Vancouver, British Columbia, Canada .,2 Department of Psychiatry, Faculty of Medicine, University of British Columbia , Vancouver, British Columbia, Canada .,5 Massachusetts General Hospital , Boston, Massachusetts.,6 Harvard Medical School , Boston, Massachusetts.,7 Department of Psychiatry, BC Children's Hospital , Vancouver, British Columbia, Canada
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75
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Parent perspectives on brain scans and genetic tests for OCD: Talking of difficult presents, desired pasts, and imagined futures. BIOSOCIETIES 2017. [DOI: 10.1057/s41292-017-0046-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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76
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Platt MP, Agalliu D, Cutforth T. Hello from the Other Side: How Autoantibodies Circumvent the Blood-Brain Barrier in Autoimmune Encephalitis. Front Immunol 2017; 8:442. [PMID: 28484451 PMCID: PMC5399040 DOI: 10.3389/fimmu.2017.00442] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/30/2017] [Indexed: 12/11/2022] Open
Abstract
Antibodies against neuronal receptors and synaptic proteins are associated with autoimmune encephalitides (AE) that produce movement and psychiatric disorders. In order to exert their pathological effects on neural circuits, autoantibodies against central nervous system (CNS) targets must gain access to the brain and spinal cord by crossing the blood–brain barrier (BBB), a tightly regulated gateway formed by endothelial cells lining CNS blood vessels. To date, the pathogenic mechanisms that underlie autoantibody-triggered encephalitic syndromes are poorly understood, and how autoantibodies breach the barrier remains obscure for almost all AE syndromes. The relative importance of cellular versus humoral immune mechanisms for disease pathogenesis also remains largely unexplored. Here, we review the proposed triggers for various autoimmune encephalopathies and their animal models, as well as basic structural features of the BBB and how they differ among various CNS regions, a feature that likely underlies some regional aspects of autoimmune encephalitis pathogenesis. We then discuss the routes that antibodies and immune cells employ to enter the CNS and their implications for AE. Finally, we explore future therapeutic strategies that may either preserve or restore barrier function and thereby limit immune cell and autoantibody infiltration into the CNS. Recent mechanistic insights into CNS autoantibody entry indicate promising future directions for therapeutic intervention beyond current, short-lived therapies that eliminate circulating autoantibodies.
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Affiliation(s)
- Maryann P Platt
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Dritan Agalliu
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA.,Department of Pharmacology, Columbia University Medical Center, New York, NY, USA.,Columbia Translational Neuroscience Initiative, Columbia University Medical Center, New York, NY, USA
| | - Tyler Cutforth
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Columbia Translational Neuroscience Initiative, Columbia University Medical Center, New York, NY, USA
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77
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Dalmau J, Geis C, Graus F. Autoantibodies to Synaptic Receptors and Neuronal Cell Surface Proteins in Autoimmune Diseases of the Central Nervous System. Physiol Rev 2017; 97:839-887. [PMID: 28298428 PMCID: PMC5539405 DOI: 10.1152/physrev.00010.2016] [Citation(s) in RCA: 340] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Investigations in the last 10 years have revealed a new category of neurological diseases mediated by antibodies against cell surface and synaptic proteins. There are currently 16 such diseases all characterized by autoantibodies against neuronal proteins involved in synaptic signaling and plasticity. In clinical practice these findings have changed the diagnostic and treatment approach to potentially lethal, but now treatable, neurological and psychiatric syndromes previously considered idiopathic or not even suspected to be immune-mediated. Studies show that patients' antibodies can impair the surface dynamics of the target receptors eliminating them from synapses (e.g., NMDA receptor), block the function of the antigens without changing their synaptic density (e.g., GABAb receptor), interfere with synaptic protein-protein interactions (LGI1, Caspr2), alter synapse formation (e.g., neurexin-3α), or by unclear mechanisms associate to a new form of tauopathy (IgLON5). Here we first trace the process of discovery of these diseases, describing the triggers and symptoms related to each autoantigen, and then review in detail the structural and functional alterations caused by the autoantibodies with special emphasis in those (NMDA receptor, amphiphysin) that have been modeled in animals.
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Affiliation(s)
- Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Christian Geis
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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78
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Sinmaz N, Tea F, Pilli D, Zou A, Amatoury M, Nguyen T, Merheb V, Ramanathan S, Cooper ST, Dale RC, Brilot F. Dopamine-2 receptor extracellular N-terminus regulates receptor surface availability and is the target of human pathogenic antibodies from children with movement and psychiatric disorders. Acta Neuropathol Commun 2016; 4:126. [PMID: 27908295 PMCID: PMC5134269 DOI: 10.1186/s40478-016-0397-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 11/23/2016] [Indexed: 12/17/2022] Open
Abstract
Anti-Dopamine-2 receptor (D2R) antibodies have been recently identified in a subgroup of children with autoimmune movement and psychiatric disorders, however the epitope(s) and mechanism of pathogenicity remain unknown. Here we report a major biological role for D2R extracellular N-terminus as a regulator of receptor surface availability, and as a major epitope targeted and impaired in brain autoimmunity. In transfected human cells, purified anti-D2R antibody from patients specifically and significantly reduced human D2R surface levels. Next, human D2R mutants modified in their extracellular domains were subcloned, and we analyzed the region bound by 35 anti-D2R antibody-positive patient sera using quantitative flow cytometry on live transfected cells. We found that N-glycosylation at amino acids N5 and/or N17 was critical for high surface expression in interaction with the last 15 residues of extracellular D2R N-terminus. No anti-D2R antibody-positive patient sera bound to the three extracellular loops, but all patient sera (35/35) targeted the extracellular N-terminus. Overall, patient antibody binding was dependent on two main regions encompassing amino acids 20 to 29, and 23 to 37. Residues 20 to 29 contributed to the majority of binding (77%, 27/35), among which 26% (7/27) sera bound to amino acids R20, P21, and F22, 37% (10/27) patients were dependent on residues at positions 26 and 29, that are different between humans and mice, and 30% (8/27) sera required R20, P21, F22, N23, D26, and A29. Seven patient sera bound to the region 23 to 37 independently of D26 and A29, but most sera exhibited N-glycosylation-independent epitope recognition at N23. Interestingly, no evident segregation of binding pattern according to patient clinical phenotype was observed. D2R N-terminus is a central epitope in autoimmune movement and psychiatric disorders and this knowledge could help the design of novel specific immune therapies tailored to improve patient outcome.
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79
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Williams KA, Swedo SE, Farmer CA, Grantz H, Grant PJ, D'Souza P, Hommer R, Katsovich L, King RA, Leckman JF. Randomized, Controlled Trial of Intravenous Immunoglobulin for Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections. J Am Acad Child Adolesc Psychiatry 2016; 55:860-867.e2. [PMID: 27663941 DOI: 10.1016/j.jaac.2016.06.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/15/2016] [Accepted: 07/28/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are hypothesized to occur as a result of cross-reactive antibodies produced in response to group A streptococcal infections. Previous research suggests that immunomodulatory therapies, such as intravenous immunoglobulin (IVIG), may lead to rapid and sustained symptom improvement in patients with PANDAS. METHOD A total of 35 children meeting criteria for PANDAS and moderate to severe obsessive-compulsive disorder (OCD) were enrolled in a randomized-entry, double-blind, placebo-controlled, 6-week trial of IVIG (1 g/kg/day on 2 consecutive days), followed by optional open-label treatment for nonresponders, with follow-up at 12 and 24 weeks. Primary outcome measures were the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Clinical Global Impressions-Improvement (CGI-I) rating. "Responders" were defined, a priori, by a ≥ 30% decrease in CY-BOCS total score, and a "much" or "very much" improved rating on CGI-I. RESULTS During the double-blind phase, the mean decrease in CY-BOCS score was 24% ± 31% in the IVIG group (n = 17) and 12% ± 27% in the placebo group (n = 18), with six responders in the IVIG group (35%) versus four (22%) in the placebo group; these differences were not statistically significant. Twenty-four participants met criteria for nonresponse to double-blind infusion and received open-label IVIG at week 6. Among all participants, the mean CY-BOCS improvement from baseline was 55% ± 33% at week 12 and 62% ± 33% at week 24. CONCLUSION IVIG was safe and well tolerated. Between-group differences were smaller than anticipated, and the double-blind comparison failed to demonstrate superiority of IVIG over placebo. The observed open-label improvements indicate that future trials would benefit from larger sample sizes designed in part to aid in the identification of biomarkers predictive of a positive response to immunotherapy. Future investigations focused on the natural history of PANDAS are also warranted. Clinical trial registration information-Intravenous Immunoglobulin for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections); http://clinicaltrials.gov/; NCT01281969ZIAMH002666.
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Affiliation(s)
- Kyle A Williams
- Child Study Center at Yale University School of Medicine, New Haven, CT; Pediatric Neuropsychiatry and Immunology Program at Massachusetts General Hospital, Boston, MA
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD.
| | - Cristan A Farmer
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Heidi Grantz
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - Paul J Grant
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Precilla D'Souza
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Rebecca Hommer
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Liliya Katsovich
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - Robert A King
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - James F Leckman
- Child Study Center at Yale University School of Medicine, New Haven, CT
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80
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Rodent models of obsessive compulsive disorder: Evaluating validity to interpret emerging neurobiology. Neuroscience 2016; 345:256-273. [PMID: 27646291 DOI: 10.1016/j.neuroscience.2016.09.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/03/2016] [Accepted: 09/08/2016] [Indexed: 11/21/2022]
Abstract
Obsessive Compulsive Disorder (OCD) is a common neuropsychiatric disorder with unknown molecular underpinnings. Identification of genetic and non-genetic risk factors has largely been elusive, primarily because of a lack of power. In contrast, neuroimaging has consistently implicated the cortico-striatal-thalamo-cortical circuits in OCD. Pharmacological treatment studies also show specificity, with consistent response of OCD symptoms to chronic treatment with serotonin reuptake inhibitors; although most patients are left with residual impairment. In theory, animal models could provide a bridge from the neuroimaging and pharmacology data to an understanding of pathophysiology at the cellular and molecular level. Several mouse models have been proposed using genetic, immunological, pharmacological, and optogenetic tools. These experimental model systems allow testing of hypotheses about the origins of compulsive behavior. Several models have generated behavior that appears compulsive-like, particularly excessive grooming, and some have demonstrated response to chronic serotonin reuptake inhibitors, establishing both face validity and predictive validity. Construct validity is more difficult to establish in the context of a limited understanding of OCD risk factors. Our current models may help us to dissect the circuits and molecular pathways that can elicit OCD-relevant behavior in rodents. We can hope that this growing understanding, coupled with developing technology, will prepare us when robust OCD risk factors are better understood.
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81
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Gorton D, Sikder S, Williams NL, Chilton L, Rush CM, Govan BL, Cunningham MW, Ketheesan N. Repeat exposure to group A streptococcal M protein exacerbates cardiac damage in a rat model of rheumatic heart disease. Autoimmunity 2016; 49:563-570. [PMID: 27562362 PMCID: PMC5177596 DOI: 10.1080/08916934.2016.1217999] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Rheumatic fever and rheumatic heart disease (RF/RHD) develop following repeated infection with group A streptococci (GAS). We used the Rat Autoimmune Valvulitis (RAV) model of RF/RHD to demonstrate that repetitive booster immunization with GAS-derived recombinant M protein (rM5) resulted in an enhanced anti-cardiac myosin antibody response that may contribute to the breaking of immune tolerance leading to RF/RHD and increased infiltration of heart valves by mononuclear cells. With each boost, more inflammatory cells were observed infiltrating heart tissue which could lead to severe cardiac damage. We also found evidence that both complement and anti-M protein antibodies in serum from rM5-immunized rats have the potential to contribute to inflammation in heart valves by activating cardiac endothelium. More importantly, we have demonstrated by electrocardiography for the first time in the RAV model that elongation of P-R interval follows repetitive boost with rM5. Our observations provide experimental evidence for cardiac alterations following repeated exposure to GAS M protein with immunological and electrophysiological features resembling that seen in humans following recurrent GAS infection.
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Affiliation(s)
- Davina Gorton
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
| | - Suchandan Sikder
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
| | - Natasha L Williams
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
| | - Lisa Chilton
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
| | - Catherine M Rush
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
| | - Brenda L Govan
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
| | - Madeleine W Cunningham
- b Department of Microbiology and Immunology , University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - Natkunam Ketheesan
- a Biomedicine, College of Public Health, Medical & Veterinary Sciences, and Australian Institute of Tropical Health and Medicine, James Cook University , Townsville , Australia and
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82
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Spinello C, Laviola G, Macrì S. Pediatric Autoimmune Disorders Associated with Streptococcal Infections and Tourette's Syndrome in Preclinical Studies. Front Neurosci 2016; 10:310. [PMID: 27445678 PMCID: PMC4928151 DOI: 10.3389/fnins.2016.00310] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 06/20/2016] [Indexed: 01/08/2023] Open
Abstract
Accumulating evidence suggests that Tourette's Syndrome (TS) - a multifactorial pediatric disorder characterized by the recurrent exhibition of motor tics and/or vocal utterances - can partly depend on immune dysregulation provoked by early repeated streptococcal infections. The natural and adaptive antibody-mediated reaction to streptococcus has been proposed to potentially turn into a pathological autoimmune response in vulnerable individuals. Specifically, in conditions of increased permeability of the blood brain barrier (BBB), streptococcus-induced antibodies have been proposed to: (i) reach neuronal targets located in brain areas responsible for motion control; and (ii) contribute to the exhibition of symptoms. This theoretical framework is supported by indirect evidence indicating that a subset of TS patients exhibit elevated streptococcal antibody titers upon tic relapses. A systematic evaluation of this hypothesis entails preclinical studies providing a proof of concept of the aforementioned pathological sequelae. These studies shall rest upon individuals characterized by a vulnerable immune system, repeatedly exposed to streptococcus, and carefully screened for phenotypes isomorphic to the pathological signs of TS observed in patients. Preclinical animal models may thus constitute an informative, useful tool upon which conducting targeted, hypothesis-driven experiments. In the present review we discuss the available evidence in preclinical models in support of the link between TS and pediatric autoimmune neuropsychiatric disorders associated with streptococcus infections (PANDAS), and the existing gaps that future research shall bridge. Specifically, we report recent preclinical evidence indicating that the immune responses to repeated streptococcal immunizations relate to the occurrence of behavioral and neurological phenotypes reminiscent of TS. By the same token, we discuss the limitations of these studies: limited evidence of behavioral phenotypes isomorphic to tics and scarce knowledge about the immunological phenomena favoring the transition from natural adaptive immunity to pathological outcomes.
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Affiliation(s)
- Chiara Spinello
- Section of Behavioural Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità Roma, Italy
| | - Giovanni Laviola
- Section of Behavioural Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità Roma, Italy
| | - Simone Macrì
- Section of Behavioural Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità Roma, Italy
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83
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Hoffmann C, Zong S, Mané-Damas M, Molenaar P, Losen M, Martinez-Martinez P. Autoantibodies in Neuropsychiatric Disorders. Antibodies (Basel) 2016; 5:antib5020009. [PMID: 31557990 PMCID: PMC6698850 DOI: 10.3390/antib5020009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/01/2016] [Accepted: 04/06/2016] [Indexed: 12/15/2022] Open
Abstract
Little is known about the etiology of neuropsychiatric disorders. The identification of autoantibodies targeting the N-methyl-d-aspartate receptor (NMDA-R), which causes neurological and psychiatric symptoms, has reinvigorated the hypothesis that other patient subgroups may also suffer from an underlying autoimmune condition. In recent years, a wide range of neuropsychiatric diseases and autoantibodies targeting ion-channels or neuronal receptors including NMDA-R, voltage gated potassium channel complex (VGKC complex), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R), γ-aminobutyric acid receptor (GABA-R) and dopamine receptor (DR) were studied and conflicting reports have been published regarding the seroprevalence of these autoantibodies. A clear causative role of autoantibodies on psychiatric symptoms has as yet only been shown for the NMDA-R. Several other autoantibodies have been related to the presence of certain symptoms and antibody effector mechanisms have been proposed. However, extensive clinical studies with large multicenter efforts to standardize diagnostic procedures for autoimmune etiology and animal studies are needed to confirm the pathogenicity of these autoantibodies. In this review, we discuss the current knowledge of neuronal autoantibodies in the major neuropsychiatric disorders: psychotic, major depression, autism spectrum, obsessive-compulsive and attention-deficit/hyperactivity disorders.
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Affiliation(s)
- Carolin Hoffmann
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Shenghua Zong
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Marina Mané-Damas
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Peter Molenaar
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Mario Losen
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Pilar Martinez-Martinez
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
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84
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Nespoli E, Rizzo F, Boeckers TM, Hengerer B, Ludolph AG. Addressing the Complexity of Tourette's Syndrome through the Use of Animal Models. Front Neurosci 2016; 10:133. [PMID: 27092043 PMCID: PMC4824761 DOI: 10.3389/fnins.2016.00133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/16/2016] [Indexed: 01/06/2023] Open
Abstract
Tourette's syndrome (TS) is a neurodevelopmental disorder characterized by fluctuating motor and vocal tics, usually preceded by sensory premonitions, called premonitory urges. Besides tics, the vast majority—up to 90%—of TS patients suffer from psychiatric comorbidities, mainly attention deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). The etiology of TS remains elusive. Genetics is believed to play an important role, but it is clear that other factors contribute to TS, possibly altering brain functioning and architecture during a sensitive phase of neural development. Clinical brain imaging and genetic studies have contributed to elucidate TS pathophysiology and disease mechanisms; however, TS disease etiology still is poorly understood. Findings from genetic studies led to the development of genetic animal models, but they poorly reflect the pathophysiology of TS. Addressing the role of neurotransmission, brain regions, and brain circuits in TS disease pathomechanisms is another focus area for preclinical TS model development. We are now in an interesting moment in time when numerous innovative animal models are continuously brought to the attention of the public. Due to the diverse and largely unknown etiology of TS, there is no single preclinical model featuring all different aspects of TS symptomatology. TS has been dissected into its key symptomst hat have been investigated separately, in line with the Research Domain Criteria concept. The different rationales used to develop the respective animal models are critically reviewed, to discuss the potential of the contribution of animal models to elucidate TS disease mechanisms.
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Affiliation(s)
- Ester Nespoli
- Competence in Neuro Spine Department, Boehringer Ingelheim Pharma GmbH & Co. KGBiberach an der Riss, Germany; Department of Child and Adolescence Psychiatry/Psychotherapy, University of UlmUlm, Germany
| | - Francesca Rizzo
- Department of Child and Adolescence Psychiatry/Psychotherapy, University of UlmUlm, Germany; Institute of Anatomy and Cell Biology, University of UlmUlm, Germany
| | - Tobias M Boeckers
- Institute of Anatomy and Cell Biology, University of Ulm Ulm, Germany
| | - Bastian Hengerer
- Competence in Neuro Spine Department, Boehringer Ingelheim Pharma GmbH & Co. KG Biberach an der Riss, Germany
| | - Andrea G Ludolph
- Department of Child and Adolescence Psychiatry/Psychotherapy, University of Ulm Ulm, Germany
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85
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Cutforth T, DeMille MM, Agalliu I, Agalliu D. CNS autoimmune disease after Streptococcus pyogenes infections: animal models, cellular mechanisms and genetic factors. FUTURE NEUROLOGY 2016; 11:63-76. [PMID: 27110222 DOI: 10.2217/fnl.16.4] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Streptococcus pyogenes infections have been associated with two autoimmune diseases of the CNS: Sydenham's chorea (SC) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS). Despite the high frequency of pharyngeal streptococcus infections among children, only a small fraction develops SC or PANDAS. This suggests that several factors in combination are necessary to trigger autoimmune complications: specific S. pyogenes strains that induce a strong immune response toward the host nervous system; genetic susceptibility that predispose children toward an autoimmune response involving movement or tic symptoms; and multiple infections of the throat or tonsils that lead to a robust Th17 cellular and humoral immune response when untreated. In this review, we summarize the evidence for each factor and propose that all must be met for the requisite neurovascular pathology and behavioral deficits found in SC/PANDAS.
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Affiliation(s)
- Tyler Cutforth
- Department of Neurology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA
| | - Mellissa Mc DeMille
- Department of Pediatrics, Yale Child Health Research Center, Yale University School of Medicine, 464 Congress Avenue, Suite S208, New Haven, CT 06519, USA
| | - Ilir Agalliu
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave., Room 1315-B, Bronx, NY 10461, USA
| | - Dritan Agalliu
- Department of Neurology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA; Departments of Pathology & Cell Biology & Pharmacology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA
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86
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Carapetis JR, Beaton A, Cunningham MW, Guilherme L, Karthikeyan G, Mayosi BM, Sable C, Steer A, Wilson N, Wyber R, Zühlke L. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers 2016; 2:15084. [PMID: 27188830 PMCID: PMC5810582 DOI: 10.1038/nrdp.2015.84] [Citation(s) in RCA: 310] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF, which can result from a single severe episode or from multiple recurrent episodes of the illness, is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in resource-poor settings around the world. Although our understanding of disease pathogenesis has advanced in recent years, this has not led to dramatic improvements in diagnostic approaches, which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed, penicillin has been the mainstay of treatment for decades and there is no other treatment that has been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent advances - including the use of echocardiographic diagnosis in those with ARF and in screening for early detection of RHD, progress in developing group A streptococcal vaccines and an increased focus on the lived experience of those with RHD and the need to improve quality of life - give cause for optimism that progress will be made in coming years against this neglected disease that affects populations around the world, but is a particular issue for those living in poverty.
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Affiliation(s)
- Jonathan R Carapetis
- Telethon Kids Institute, the University of Western Australia, PO Box 855, West Perth, Western Australia 6872, Australia
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Andrea Beaton
- Children's National Health System, Washington, District of Columbia, USA
| | - Madeleine W Cunningham
- Department of Microbiology and Immunology, Biomedical Research Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Luiza Guilherme
- Heart Institute (InCor), University of São Paulo, School of Medicine, São Paulo, Brazil
- Institute for Immunology Investigation, National Institute for Science and Technology, São Paulo, Brazil
| | - Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Bongani M Mayosi
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Craig Sable
- Children's National Health System, Washington, District of Columbia, USA
| | - Andrew Steer
- Department of Paediatrics, the University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Hospital, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Rosemary Wyber
- Telethon Kids Institute, the University of Western Australia, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Liesl Zühlke
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Department of Paediatric Cardiology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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87
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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88
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Pollak TA, Beck K, Irani SR, Howes OD, David AS, McGuire PK. Autoantibodies to central nervous system neuronal surface antigens: psychiatric symptoms and psychopharmacological implications. Psychopharmacology (Berl) 2016; 233:1605-21. [PMID: 26667479 PMCID: PMC4828500 DOI: 10.1007/s00213-015-4156-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/05/2015] [Indexed: 12/30/2022]
Abstract
RATIONALE Autoantibodies to central nervous system (CNS) neuronal surface antigens have been described in association with autoimmune encephalopathies which prominently feature psychiatric symptoms in addition to neurological symptoms. The potential role of these autoantibodies in primary psychiatric diseases such as schizophrenia or bipolar affective disorder is of increasing interest. OBJECTIVES We aimed to review the nature of psychiatric symptoms associated with neuronal surface autoantibodies, in the context of autoimmune encephalopathies as well as primary psychiatric disorders, and to review the mechanisms of action of these autoantibodies from a psychopharmacological perspective. RESULTS The functional effects of the autoantibodies on their target antigens are described; their clinical expression is at least in part mediated by their effects on neuronal receptor function, primarily at the synapse, usually resulting in receptor hypofunction. The psychiatric effects of the antibodies are related to known functions of the receptor target or its complexed proteins, with reference to supportive genetic and pharmacological evidence where relevant. Evidence for a causal role of these autoantibodies in primary psychiatric disease is increasing but remains controversial; relevant methodological controversies are outlined. Non-receptor-based mechanisms of autoantibody action, including neuroinflammatory mechanisms, and therapeutic implications are discussed. CONCLUSIONS An analysis of the autoantibodies from a psychopharmacological perspective, as endogenous, bioactive, highly specific, receptor-targeting molecules, provides a valuable opportunity to understand the neurobiological basis of associated psychiatric symptoms. Potentially, new treatment strategies will emerge from the improving understanding of antibody-antigen interaction within the CNS.
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Affiliation(s)
- T A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
| | - K Beck
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - S R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - O D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - A S David
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - P K McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
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89
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Cunningham MW, Cox CJ. Autoimmunity against dopamine receptors in neuropsychiatric and movement disorders: a review of Sydenham chorea and beyond. Acta Physiol (Oxf) 2016; 216:90-100. [PMID: 26454143 PMCID: PMC5812018 DOI: 10.1111/apha.12614] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 02/26/2015] [Accepted: 09/23/2015] [Indexed: 12/16/2022]
Abstract
Antineuronal autoantibodies are associated with the involuntary movement disorder Sydenham chorea (SC) and paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) which are characterized by the acute onset of tics and/or obsessive compulsive disorder (OCD). In SC and PANDAS, autoantibodies signal human neuronal cells and activate calcium calmodulin-dependent protein kinase II (CaMKII). Animal models immunized with group A streptococcal antigens demonstrate autoantibodies against dopamine receptors and concomitantly altered behaviours. Human monoclonal antibodies (mAbs) derived from SC target and signal the dopamine D2L (long) receptor (D2R). Antibodies against D2R were elevated over normal levels in SC and acute-onset PANDAS with small choreiform movements, but were not elevated over normal levels in PANDAS-like chronic tics and OCD. The expression of human SC-derived anti-D2R autoantibody V gene in B cells and serum of transgenic mice demonstrated that the human autoantibody targets dopaminergic neurones in the basal ganglia and other types of neurones in the cortex. Here, we review current evidence supporting the hypothesis that antineuronal antibodies, specifically against dopamine receptors, follow streptococcal exposures and may target dopamine receptors and alter central dopamine pathways leading to movement and neuropsychiatric disorders.
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Affiliation(s)
- M W Cunningham
- Department of Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - C J Cox
- Department of Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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90
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Dileepan T, Smith ED, Knowland D, Hsu M, Platt M, Bittner-Eddy P, Cohen B, Southern P, Latimer E, Harley E, Agalliu D, Cleary PP. Group A Streptococcus intranasal infection promotes CNS infiltration by streptococcal-specific Th17 cells. J Clin Invest 2015; 126:303-17. [PMID: 26657857 DOI: 10.1172/jci80792] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 11/05/2015] [Indexed: 12/20/2022] Open
Abstract
Group A streptococcal (GAS) infection induces the production of Abs that cross-react with host neuronal proteins, and these anti-GAS mimetic Abs are associated with autoimmune diseases of the CNS. However, the mechanisms that allow these Abs to cross the blood-brain barrier (BBB) and induce neuropathology remain unresolved. We have previously shown that GAS infection in mouse models induces a robust Th17 response in nasal-associated lymphoid tissue (NALT). Here, we identified GAS-specific Th17 cells in tonsils of humans naturally exposed to GAS, prompting us to explore whether GAS-specific CD4+ T cells home to mouse brains following i.n. infection. Intranasal challenge of repeatedly GAS-inoculated mice promoted migration of GAS-specific Th17 cells from NALT into the brain, BBB breakdown, serum IgG deposition, microglial activation, and loss of excitatory synaptic proteins under conditions in which no viable bacteria were detected in CNS tissue. CD4+ T cells were predominantly located in the olfactory bulb (OB) and in other brain regions that receive direct input from the OB. Together, these findings provide insight into the immunopathology of neuropsychiatric complications that are associated with GAS infections and suggest that crosstalk between the CNS and cellular immunity may be a general mechanism by which infectious agents exacerbate symptoms associated with other CNS autoimmune disorders.
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91
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Antibodies as Mediators of Brain Pathology. Trends Immunol 2015; 36:709-724. [PMID: 26494046 DOI: 10.1016/j.it.2015.09.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/17/2015] [Accepted: 09/17/2015] [Indexed: 01/04/2023]
Abstract
The brain is normally sequestered from antibody exposure by the blood brain barrier. However, antibodies can access the brain during fetal development before the barrier achieves full integrity, and in disease states when barrier integrity is compromised. Recent studies suggest that antibodies contribute to brain pathology associated with autoimmune diseases such as systemic lupus erythematosus and neuromyelitis optica, and can lead to transient or permanent behavioral or cognitive abnormalities. We review these findings here and examine the circumstances associated with antibody entry into the brain, the routes of access and the mechanisms that then effect pathology. Understanding these processes and the nature and specificity of neuronal autoantibodies may reveal therapeutic strategies toward alleviating or preventing the neurological pathologies and behavioral abnormalities associated with autoimmune disease.
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92
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Macrì S, Ceci C, Proietti Onori M, Invernizzi RW, Bartolini E, Altabella L, Canese R, Imperi M, Orefici G, Creti R, Margarit I, Magliozzi R, Laviola G. Mice repeatedly exposed to Group-A β-Haemolytic Streptococcus show perseverative behaviors, impaired sensorimotor gating, and immune activation in rostral diencephalon. Sci Rep 2015; 5:13257. [PMID: 26304458 PMCID: PMC4548234 DOI: 10.1038/srep13257] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/09/2015] [Indexed: 01/24/2023] Open
Abstract
Repeated exposure to Group-A β-Haemolytic Streptococcus (GAS) may constitute a vulnerability factor in the onset and course of pediatric motor disturbances. GAS infections/colonization can stimulate the production of antibodies, which may cross the blood brain barrier, target selected brain areas (e.g. basal ganglia), and exacerbate motor alterations. Here, we exposed developing SJL male mice to four injections with a GAS homogenate and evaluated the following domains: motor coordination; general locomotion; repetitive behaviors; perseverative responses; and sensorimotor gating (pre-pulse inhibition, PPI). To demonstrate that behavioral changes were associated with immune-mediated brain alterations, we analyzed, in selected brain areas, the presence of infiltrates and microglial activation (immunohistochemistry), monoamines (HPLC), and brain metabolites (in vivo Magnetic Resonance Spectroscopy). GAS-exposed mice showed increased repetitive and perseverative behaviors, impaired PPI, and reduced concentrations of serotonin in prefrontal cortex, a brain area linked to the behavioral domains investigated, wherein they also showed remarkable elevations in lactate. Active inflammatory processes were substantiated by the observation of infiltrates and microglial activation in the white matter of the anterior diencephalon. These data support the hypothesis that repeated GAS exposure may elicit inflammatory responses in brain areas involved in motor control and perseverative behavior, and result in phenotypic abnormalities.
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Affiliation(s)
- Simone Macrì
- Sect. Behavioural Neuroscience, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Chiara Ceci
- Sect. Behavioural Neuroscience, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Martina Proietti Onori
- Sect. Behavioural Neuroscience, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | | | - Erika Bartolini
- Research Centre, Novartis Vaccines and Diagnostics, Via Fiorentina 1, 53100 Siena, Italy
| | - Luisa Altabella
- Sect. Molecular and Cellular Imaging, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Rossella Canese
- Sect. Molecular and Cellular Imaging, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Monica Imperi
- Sect. Respiratory and Systemic Bacterial Diseases, Dept. of Infectious, Parasitic, and Immune-mediated Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Graziella Orefici
- Sect. Respiratory and Systemic Bacterial Diseases, Dept. of Infectious, Parasitic, and Immune-mediated Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Roberta Creti
- Sect. Respiratory and Systemic Bacterial Diseases, Dept. of Infectious, Parasitic, and Immune-mediated Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Immaculada Margarit
- Research Centre, Novartis Vaccines and Diagnostics, Via Fiorentina 1, 53100 Siena, Italy
| | - Roberta Magliozzi
- Sect. Demyelinating and Inflammatory Diseases of the CNS, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
| | - Giovanni Laviola
- Sect. Behavioural Neuroscience, Dept. Cell Biology &Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena, 299, I-00161 Roma, Italy
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93
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Sinmaz N, Amatoury M, Merheb V, Ramanathan S, Dale RC, Brilot F. Autoantibodies in movement and psychiatric disorders: updated concepts in detection methods, pathogenicity, and CNS entry. Ann N Y Acad Sci 2015; 1351:22-38. [DOI: 10.1111/nyas.12764] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Nese Sinmaz
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Mazen Amatoury
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Vera Merheb
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Sudarshini Ramanathan
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Russell C. Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
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94
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Abstract
Antibody-mediated diseases of the central nervous system are a relatively new and challenging field in autoimmune neurologic disease and of major clinical importance in children and adults. The antibodies bind to cell-surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The presence of seizures, movement disorders, autonomic dysfunction and sleep disorders, alongside neuroimaging and electrophysiological features may indicate a specific antibody-mediated disorder. However, phenotypic variation may be observed in children with the same antibody. Regardless, many patients benefit from immunotherapy with substantial improvement.
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Affiliation(s)
- Ming Lim
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK; Children's Neurosciences, Evelina Children's Hospital @ Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, Lambeth Palace Road, London SE1 7EH, UK.
| | - Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK.
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95
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Walker KG, de Vries PJ, Stein DJ, Wilmshurst JM. Sydenham Chorea and PANDAS in South Africa: Review of Evidence and Recommendations for Management in Resource-Poor Countries. J Child Neurol 2015; 30:850-9. [PMID: 25227516 DOI: 10.1177/0883073814544704] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/28/2014] [Indexed: 11/15/2022]
Abstract
In South Africa, and worldwide, rheumatic fever represents a public health problem. Improved diagnosis and management of Sydenham chorea, a major manifestation of acute rheumatic fever is key to prevention of rheumatic heart disease. This article reviews Sydenham chorea from its original description to current opinions. Recommendations are founded on expert opinion as class 1 data is lacking. This South African perspective is relevant to resource-poor settings globally insofar as it provides diagnosis and management recommendations for primary- and secondary-level healthcare professionals who care for patients in such environments. Four basic tenets of care are recommended, namely, elimination of the streptococcal infection, symptomatic treatment, immunological treatment, and nonpharmacologic interventions. A user-friendly outcome measurement tool, viable for use in low-resource settings is presented. Introduction of this tool may lead to increased awareness of the neuropsychiatric manifestations of poststreptococcal movement disorders in Africa, where reports are limited.
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Affiliation(s)
- Kathleen G Walker
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa Rheumatic Fever Clinic, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Petrus J de Vries
- Division of Child & Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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96
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Martin WJ, Steer AC, Smeesters PR, Keeble J, Inouye M, Carapetis J, Wicks IP. Post-infectious group A streptococcal autoimmune syndromes and the heart. Autoimmun Rev 2015; 14:710-25. [PMID: 25891492 DOI: 10.1016/j.autrev.2015.04.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/10/2015] [Indexed: 12/16/2022]
Abstract
There is a pressing need to reduce the high global disease burden of rheumatic heart disease (RHD) and its harbinger, acute rheumatic fever (ARF). ARF is a classical example of an autoimmune syndrome and is of particular immunological interest because it follows a known antecedent infection with group A streptococcus (GAS). However, the poorly understood immunopathology of these post-infectious diseases means that, compared to much progress in other immune-mediated diseases, we still lack useful biomarkers, new therapies or an effective vaccine in ARF and RHD. Here, we summarise recent literature on the complex interaction between GAS and the human host that culminates in ARF and the subsequent development of RHD. We contrast ARF with other post-infectious streptococcal immune syndromes - post-streptococcal glomerulonephritis (PSGN) and the still controversial paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), in order to highlight the potential significance of variations in the host immune response to GAS. We discuss a model for the pathogenesis of ARF and RHD in terms of current immunological concepts and the potential for application of in depth "omics" technologies to these ancient scourges.
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Affiliation(s)
- William John Martin
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia.
| | - Andrew C Steer
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Pierre Robert Smeesters
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Joanne Keeble
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Michael Inouye
- Medical Systems Biology, Department of Pathology and Department of Microbiology and Immunology, University of Melbourne, VIC 3010, Australia
| | | | - Ian P Wicks
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Rheumatology Unit, Royal Melbourne Hospital, Parkville, VIC 3052, Australia.
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97
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Neuronal antibody biomarkers for Sydenham's chorea identify a new group of children with chronic recurrent episodic acute exacerbations of tic and obsessive compulsive symptoms following a streptococcal infection. PLoS One 2015; 10:e0120499. [PMID: 25793715 PMCID: PMC4368605 DOI: 10.1371/journal.pone.0120499] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/23/2015] [Indexed: 12/15/2022] Open
Abstract
Several autoantibodies (anti-dopamine 1 (D1R) and 2 (D2R) receptors, anti-tubulin, anti-lysoganglioside-GM1) and antibody-mediated activation of calcium calmodulin dependent protein kinase II (CaMKII) signaling activity are elevated in children with Sydenham’s chorea (SC). Recognizing proposed clinical and autoimmune similarities between SC and PANDAS (pediatric autoimmune neuropsychiatric disorder associated with a streptococcal infection), we sought to identify serial biomarker changes in a slightly different population. Antineuronal antibodies were measured in eight children (mean 11.3 years) with chronic, dramatic, recurrent tics and obsessive-compulsive disorder (OCD) associated with a group A β-hemolytic streptococcal (GABHS) respiratory tract infection, but differing because they lacked choreiform movements. Longitudinal serum samples in most subjects included two pre-exacerbation samples, Exac), one midst Exac (abrupt recurrence of tic/OCD; temporally association with a GABHS infection in six of eight subjects), and two post-Exac. Controls included four groups of unaffected children (n = 70; mean 10.8 years) obtained at four different institutions and published controls. Clinical exacerbations were not associated with a significant rise in antineuronal antibody titers. CaMKII activation was increased at the GABHS exacerbation point in 5/6 subjects, exceeded combined and published control’s 95th percentile at least once in 7/8 subjects, and median values were elevated at each time point. Anti-tubulin and anti-D2R titers did not differ from published or combined control group’s 95th percentile or median values. Differences in anti-lysoganglioside-GM1 and anti-D1R titers were dependent on the selected control. Variances in antibody titers and CaMKII activation were identified among the institutional control groups. Based on comparisons to published studies, results identify two groups of PANDAS: 1) a cohort, represented by this study, which lacks choreiform movements and elevated antibodies against D2R; 2) the originally reported group with choreiform movements and elevated anti-D2R antibodies, similar to SC. Increased antibody mediated CaMKII activation was found in both groups and requires further study as a potential biomarker.
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98
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Antibodies to surface dopamine-2 receptor and N-methyl-D-aspartate receptor in the first episode of acute psychosis in children. Biol Psychiatry 2015; 77:537-47. [PMID: 25168608 DOI: 10.1016/j.biopsych.2014.07.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/15/2014] [Accepted: 07/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The dopamine and glutamate hypotheses are well known in psychosis. Recently, the detection of autoantibodies against proteins expressed on the surface of cells in the central nervous system has raised the possibility that specific immune-mediated mechanisms may define a biological subgroup within psychosis, although no cohort of a first episode of psychosis in children has been investigated. METHODS Serum taken during the acute presentation of 43 children with first episode of psychosis and serum from 43 pediatric control subjects was assessed for the presence of immunoglobulin (Ig)G, IgM, or IgA antibodies to dopamine-2 receptor (D2R) and NR1 subunit of the N-methyl-D-aspartate receptor using a flow cytometry live cell-based assay and immunolabeling of murine primary neurons. RESULTS Using a cutoff of three SD above the control mean, serum antibodies to D2R or NR1 were detected in 8 of 43 psychotic patients but not detected in any of 43 control subjects (p < .001). Positive immunoglobulin binding to D2R was found in 3 of 43 psychosis patients (3 IgG, 1 IgM, 0 IgA) and to N-methyl-D-aspartate receptor in 6 of 43 patients (5 IgG, 1 IgM, 1 IgA). Specificity of antibody was confirmed by immunoaffinity purification and immunoabsorption. Significant differences in antibody binding to live, fixed, and fixed and permeabilized neurons were observed, confirming that only live cells can define surface epitope immunolabeling. CONCLUSIONS This is the first report of serum antibodies to surface D2R and NR1 in pediatric patients with isolated psychosis, which supports the hypothesis that a subgroup of patients may be immune-mediated.
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99
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Cox CJ, Zuccolo AJ, Edwards EV, Mascaro-Blanco A, Alvarez K, Stoner J, Chang K, Cunningham MW. Antineuronal antibodies in a heterogeneous group of youth and young adults with tics and obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2015; 25:76-85. [PMID: 25658702 PMCID: PMC4340634 DOI: 10.1089/cap.2014.0048] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Antineuronal antibodies have been implicated in tic and obsessive compulsive disorders (OCD) associated with group A streptococcal infections. We investigated antineuronal autoantibody levels as well as antibody-mediated neuronal cell signaling activity, as previously reported for Sydenham chorea and pediatric autoimmune neuropsychiatric disorder associated with streptococci (PANDAS), to determine immunological profiles for a large cohort of children with tics and/or OCD. METHODS Study participants (n=311; ages 4-27 years, 66% male) were selected from a larger group of individuals with self-reported neuropsychiatric symptoms (n=742) and included only those with accurate knowledge of group A streptococcal infection status, except for four individuals in whom streptococcal infection status was unknown. Healthy control samples (n=16; ages 5-14 years, 81% male), came from the National Institute of Mental Health and Yale University. In addition to serum donations, participants and/or legal guardians provided neuropsychiatric and related medical histories of symptoms that had lasted >1 year. Antineuronal immunoglobulin G (IgG) titers were measured by standard enzyme-linked immunosorbent assay (ELISA) and compared with mean titers of normal age-matched sera against lysoganglioside, tubulin, and dopamine receptors (D1R and D2R). Antibody-mediated signaling of calcium calmodulin dependent protein kinase II (CaMKII) activity in a human neuronal cell line (SK-N-SH) was tested in serum. RESULTS Of 311 individuals, 222 (71%) had evidence of group A streptococcal infection, which was associated with tics and/or OCD status (p=0.0087). Sera from individuals with tics and/or OCD (n=261) had evidence of elevated serum IgG antibodies against human D1R (p<0.0001) and lysoganglioside (p=0.0001), and higher serum activation of CaMKII activity (p<0.0001) in a human neuronal cell line compared with healthy controls (n=16). Furthermore, patients with tics and OCD had significantly increased activation of CaMKII activity compared with patients with only tics or only OCD (p<0.033 for each). CONCLUSION Our study suggested a significant correlation of streptococcal-associated tics and OCD with elevated anti-D1R and antilysoganglioside antineuronal antibodies in serum concomitant with higher activation of CaMKII in human neuronal cells. Youth and young adults with chronic tics and OCD may have underlying infectious/immunologic etiology.
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Affiliation(s)
- Carol J. Cox
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amir J. Zuccolo
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Erica V. Edwards
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Adita Mascaro-Blanco
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kathy Alvarez
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Julie Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kiki Chang
- Department of Psychiatry and Behavioral Sciences, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, California
| | - Madeleine W. Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Latimer ME, L'Etoile N, Seidlitz J, Swedo SE. Therapeutic plasma apheresis as a treatment for 35 severely ill children and adolescents with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. J Child Adolesc Psychopharmacol 2015; 25:70-5. [PMID: 25658452 PMCID: PMC4340509 DOI: 10.1089/cap.2014.0080] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Because of its reported similarities to Sydenham chorea, therapeutic plasma apheresis (TPA) has been proposed as a potential treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). To date, support for the use of TPA has been limited to a few anecdotal reports and a small placebo-controlled trial demonstrating dramatic symptom improvements at 1 month and 1 year follow-up. To evaluate the safety and efficacy of TPA further, we undertook a retrospective review of all PANDAS patients treated with TPA at Georgetown University Hospital between August 2009 and October 2013. METHODS Forty patients were identified, and sufficient information was available from medical records and telephone interview for 35 cases (88%). All 35 (23 boys; 12 girls) met diagnostic criteria for PANDAS (Swedo et al. 1998 ) and had severe symptoms. The TPA procedures were performed at Georgetown University Hospital using a protocol that processes a total of 4.5 blood volumes over 3-5 days (three treatments of 1.5 volumes each). Overall symptom improvements at 6 months post-TPA and long-term follow-up were estimated by parents, who also rated changes in individual symptoms to provide information about patterns of improvement. RESULTS All patients were reported to have received at least some benefit from TPA, with average improvement of 65% at 6 months post-TPA and 78% at longer-term follow-up. A decrease in the number of reported symptoms also occurred, with particular improvements in obsessive-compulsive disorder (OCD), anxiety, tics, and somatic symptoms, including dysgraphia, sleep difficulties, and urinary urgency or frequency. Contrary to expectations, preceding duration of illness was not correlated with degree of improvement following TPA, suggesting that acuity of illness is not a factor affecting response. Only two adverse events were reported: both involved reopening of the site where the central line had been placed and resolved immediately following application of pressure and re-dressing of the puncture site. CONCLUSIONS Therapeutic plasma apheresis is an invasive medical intervention that should be reserved for treatment of children and adolescents who are severely affected by PANDAS. In such patients, it appears to be a safe, well-tolerated, and beneficial treatment option.
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Affiliation(s)
- M. Elizabeth Latimer
- Pediatric Neurology Practice, Washington, DC.,Georgetown University School of Medicine, Washington, DC
| | | | - Jakob Seidlitz
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Susan E. Swedo
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
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