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Martino D, Johnson I, Leckman JF. What Does Immunology Have to Do With Normal Brain Development and the Pathophysiology Underlying Tourette Syndrome and Related Neuropsychiatric Disorders? Front Neurol 2020; 11:567407. [PMID: 33041996 PMCID: PMC7525089 DOI: 10.3389/fneur.2020.567407] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022] Open
Abstract
Objective: The goal of this article is to review the past decade's literature and provide a critical commentary on the involvement of immunological mechanisms in normal brain development, as well as its role in the pathophysiology of Tourette syndrome, other Chronic tic disorders (CTD), and related neuropsychiatric disorders including Obsessive-compulsive disorder (OCD) and Attention deficit hyperactivity disorder (ADHD). Methods: We conducted a literature search using the Medline/PubMed and EMBASE electronic databases to locate relevant articles and abstracts published between 2009 and 2020, using a comprehensive list of search terms related to immune mechanisms and the diseases of interest, including both clinical and animal model studies. Results: The cellular and molecular processes that constitute our "immune system" are crucial to normal brain development and the formation and maintenance of neural circuits. It is also increasingly evident that innate and adaptive systemic immune pathways, as well as neuroinflammatory mechanisms, play an important role in the pathobiology of at least a subset of individuals with Tourette syndrome and related neuropsychiatric disorders In the conceptual framework of the holobiont theory, emerging evidence points also to the importance of the "microbiota-gut-brain axis" in the pathobiology of these neurodevelopmental disorders. Conclusions: Neural development is an enormously complex and dynamic process. Immunological pathways are implicated in several early neurodevelopmental processes including the formation and refinement of neural circuits. Hyper-reactivity of systemic immune pathways and neuroinflammation may contribute to the natural fluctuations of the core behavioral features of CTD, OCD, and ADHD. There is still limited knowledge of the efficacy of direct and indirect (i.e., through environmental modifications) immune-modulatory interventions in the treatment of these disorders. Future research also needs to focus on the key molecular pathways through which dysbiosis of different tissue microbiota influence neuroimmune interactions in these disorders, and how microbiota modification could modify their natural history. It is also possible that valid biomarkers will emerge that will guide a more personalized approach to the treatment of these disorders.
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Affiliation(s)
- Davide Martino
- Department of Clinical Neurosciences & Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Isaac Johnson
- Child Study Center, Yale University, New Haven, CT, United States
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - James F. Leckman
- Child Study Center, Yale University, New Haven, CT, United States
- Departments of Psychiatry, Pediatrics and Psychology, Yale University, New Haven, CT, United States
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102
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Chain JL, Alvarez K, Mascaro-Blanco A, Reim S, Bentley R, Hommer R, Grant P, Leckman JF, Kawikova I, Williams K, Stoner JA, Swedo SE, Cunningham MW. Autoantibody Biomarkers for Basal Ganglia Encephalitis in Sydenham Chorea and Pediatric Autoimmune Neuropsychiatric Disorder Associated With Streptococcal Infections. Front Psychiatry 2020; 11:564. [PMID: 32670106 PMCID: PMC7328706 DOI: 10.3389/fpsyt.2020.00564] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
Movement, behavioral, and neuropsychiatric disorders in children have been linked to infections and a group of anti-neuronal autoantibodies, implying dopamine receptor-mediated encephalitis within the basal ganglia. The purpose of this study was to determine if anti-neuronal biomarkers, when used as a group, confirmed the acute disease in Sydenham chorea (SC) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS). IgG autoantibodies against four neuronal autoantigens (tubulin, lysoganglioside GM1, and dopamine receptors D1 and D2) were detected in SC sera (N=8), sera and/or cerebrospinal fluid (CSF) from two groups of PANDAS cases (N=25 first group and N=35 second group), sera from Tourette's syndrome (N=18), obsessive-compulsive disorder (N=25), attention deficit hyperactivity disorder (N=18), and healthy controls (N=28) by direct enzyme-linked immunosorbent assay (ELISA). IgG specific for neuronal autoantigens was significantly elevated during the acute symptomatic phase, and the activity of calcium/calmodulin-dependent protein kinase II (CaMKII) pathway was significantly elevated in human neuronal cells. Five assays confirmed the disease in SC and in two groups of children with PANDAS. In 35 acute onset PANDAS patients, 32 sera (91.4%) were positive for one or more of the anti-neuronal autoantibodies compared with 9 of 28 healthy controls (32.1%, p<0.0001). Importantly, CSF of 32 (91.4%) PANDAS patients had one or more detectable anti-neuronal autoantibody titers and CaMKII activation. Among healthy control subjects with elevated serum autoantibody titers for individual antigens, none (0%) were positively associated with elevated positive CaMKII activation, which was a striking contrast to the sera of PANDAS subjects, who had 76-89% positive association with elevated individual autoantibody titers and positive CaMKII activity. At 6 months follow-up, symptoms improved for more than 80% of PANDAS subjects, and serum autoantibody titers also significantly decreased. Results reported herein and previously published studies in our laboratory suggest the antibody biomarkers may be a useful adjunct to clinical diagnosis of SC, PANDAS, and related disorders and are the first known group of autoantibodies detecting dopamine receptor-mediated encephalitis in children.
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Affiliation(s)
- Jennifer L. Chain
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Kathy Alvarez
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Adita Mascaro-Blanco
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sean Reim
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Rebecca Bentley
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Rebecca Hommer
- Section on Behavioral Pediatrics, National Institute of Mental Health (NIMH), Bethesda, MD, United States
| | - Paul Grant
- Section on Behavioral Pediatrics, National Institute of Mental Health (NIMH), Bethesda, MD, United States
| | - James F. Leckman
- Child Study Center, Yale School of Medicine, New Haven, CT, United States
| | - Ivana Kawikova
- Section of Pediatric Neurology, Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Kyle Williams
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Julie A. Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Susan E. Swedo
- Section on Behavioral Pediatrics, National Institute of Mental Health (NIMH), Bethesda, MD, United States
| | - Madeleine W. Cunningham
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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103
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Yadegar M, Guo S, Ricketts EJ, Zinner SH. Assessment and Management of Tic Disorders in Pediatric Primary Care Settings. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2020; 6:159-172. [PMID: 32467820 DOI: 10.1007/s40474-019-00168-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose of Review Pediatricians and other primary care providers are often the first and sole healthcare clinicians of patients who present with tics. However, limited primary care pediatric training in neuropsychiatric concerns, as well as perceived lack of comfort and preparation, make it challenging for these clinicians to confidently identify and manage tic disorders. Recent Findings Current empirical findings of tic disorder management relevant to pediatric physicians, including assessment, psychoeducation, behavioral interventions, psychotropic medications, and alternative treatments are reviewed. Summary This article discusses neuropsychiatric and medical complexities of tic disorder assessment, with particular emphasis on differential and comorbid diagnoses. Tiered referral recommendations, based on symptom severity, impairment, and consideration of comorbid conditions, are provided. Future directions for tic management, including dissemination of evidence-based treatments of tic disorders and multidisciplinary teams within pediatric primary care settings, are included.
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Affiliation(s)
- Mina Yadegar
- Univeristy of California, Los Angeles.,Boston Child Study Center - Los Angeles.,Behavioral Associates Los Angeles
| | - Sisi Guo
- Univeristy of California, Los Angeles
| | | | - Samuel H Zinner
- University of Washington School of Medicine.,Seattle Children's Hospital
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104
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Mora S, Martín-González E, Flores P, Moreno M. Neuropsychiatric consequences of childhood group A streptococcal infection: A systematic review of preclinical models. Brain Behav Immun 2020; 86:53-62. [PMID: 30818033 DOI: 10.1016/j.bbi.2019.02.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 12/21/2018] [Accepted: 02/22/2019] [Indexed: 12/14/2022] Open
Abstract
In recent years, clinical studies have shown strong epidemiological evidence of an increased risk of developing neuropsychiatric disorders after childhood exposure to streptococcal infection, including the Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS). New preclinical studies on group A streptococcus (GAS) exposure investigate how to disentangle the influences of immune activation to induce long-term neurobehavioral effects associated with neuropsychiatric disorders such as obsessive-compulsive disorder, schizophrenia or autism. The present systematic review collects neurobehavioral evidence regarding the use of GAS exposure in animal models to study the vulnerability to different neuropsychiatric disorders, improving our understanding of its possible causes and consequences, and compares its contribution with other preclinical models of immune activation in a variety of paradigms. Specifically, we reviewed the effects of postnatal GAS exposure, in comparison with post- and prenatal exposure to Lipopolysaccharide (LPS) and Polyinosinic:polycytidylic acid (Poly I:C), on the long-term effects concerning psychomotor, cognition and socioemotional outcomes in rodents. GAS exposure in animal models has revealed different behavioral alterations such as reduced locomotion and motor coordination, a deficit in sensorimotor gating, learning, working memory, altered social behavior, and increased anxiety and stereotyped behavior. Most of the results found are in accordance with other immune activation models -LPS and Poly I:C-, with some discrepancies. The systematic review of the literature supports the preclinical model of GAS exposure as a valid model for studying the neurobehavioral consequences of streptococcal infections. Future studies on streptococcal infection could contribute increasing our knowledge on preventive actions or treatments for neuropsychiatric disorders.
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Affiliation(s)
- Santiago Mora
- Department of Psychology, University of Almería, Campus de Excelencia Internacional Agroalimentario CeiA3, Almería, Spain
| | - Elena Martín-González
- Department of Psychology, University of Almería, Campus de Excelencia Internacional Agroalimentario CeiA3, Almería, Spain
| | - Pilar Flores
- Department of Psychology, University of Almería, Campus de Excelencia Internacional Agroalimentario CeiA3, Almería, Spain
| | - Margarita Moreno
- Department of Psychology, University of Almería, Campus de Excelencia Internacional Agroalimentario CeiA3, Almería, Spain.
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105
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Zheng J, Frankovich J, McKenna ES, Rowe NC, MacEachern SJ, Ng NN, Tam LT, Moon PK, Gao J, Thienemann M, Forkert ND, Yeom KW. Association of Pediatric Acute-Onset Neuropsychiatric Syndrome With Microstructural Differences in Brain Regions Detected via Diffusion-Weighted Magnetic Resonance Imaging. JAMA Netw Open 2020; 3:e204063. [PMID: 32364596 PMCID: PMC7199120 DOI: 10.1001/jamanetworkopen.2020.4063] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Epidemiological studies indicate a link between obsessive-compulsive disorder and infections, particularly streptococcal pharyngitis. Pediatric acute-onset neuropsychiatric syndrome (PANS) manifests suddenly with obsessions, compulsions, and other behavioral disturbances, often after an infectious trigger. The current working model suggests a unifying inflammatory process involving the central nervous system, particularly the basal ganglia. OBJECTIVE To investigate whether diffusion-weighted magnetic resonance imaging (DWI) detects microstructural abnormalities across the brain regions of children with PANS. DESIGN, SETTING, AND PARTICIPANTS Case-control study performed at a single-center, multidisciplinary clinic in the United States focusing on the evaluation and treatment of children with PANS. Sixty consecutive patients who underwent 3 Tesla (T) magnetic resonance imaging (MRI) before immunomodulation from September 3, 2012, to March 30, 2018, were retrospectively reviewed for study inclusion. Six patients were excluded by blinded investigators because of imaging or motion artifacts, 3 patients for major pathologies, and 17 patients for suboptimal atlas image registration. In total, 34 patients with PANS before initiation of treatment were compared with 64 pediatric control participants. MAIN OUTCOMES AND MEASURES Using atlas-based MRI analysis, regional brain volume, diffusion, and cerebral blood flow were measured in the cerebral white matter, cerebral cortex, thalamus, caudate, putamen, pallidum, hippocampus, amygdala, nucleus accumbens, and brainstem. An age and sex-controlled multivariable analysis of covariance was used to compare patients with control participants. RESULTS This study compared 34 patients with PANS (median age, 154 months; age range, 55-251 months; 17 girls and 17 boys) and 64 pediatric control participants (median age, 139 months; age range, 48-213 months); 41 girls and 23 boys). Multivariable analysis demonstrated a statistically significant difference in MRI parameters between patients with PANS and control participants (F21,74 = 6.91; P < .001; partial η2 = 0.662). All assessed brain regions had statistically significantly increased median diffusivity compared with 64 control participants. Specifically, the deep gray matter (eg, the thalamus, basal ganglia, and amygdala) demonstrated the most profound increases in diffusivity consistent with the cardinal clinical symptoms of obsessions, compulsions, emotional dysregulation, and sleep disturbances. No statistically significant differences were found regarding volume and cerebral blood flow. CONCLUSIONS AND RELEVANCE This study identifies cerebral microstructural differences in children with PANS in multiple brain structures, including the deep gray matter structures (eg, the thalamus, basal ganglia, and amygdala). Further study of MRI is warranted in prospective, clinical trials as a potential quantitative method for assessing patients under evaluation for PANS.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, California
| | - Jennifer Frankovich
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Emily S. McKenna
- Department of Radiology, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, California
| | - Nathan C. Rowe
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Nathan N. Ng
- Stanford University School of Medicine, Stanford, California
| | - Lydia T. Tam
- Stanford University School of Medicine, Stanford, California
| | - Peter K. Moon
- Stanford University School of Medicine, Stanford, California
| | - Jaynelle Gao
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Margo Thienemann
- Child and Adolescent Psychiatry and Child Development, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Nils D. Forkert
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Kristen W. Yeom
- Department of Radiology, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, California
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106
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Loffredo L, Spalice A, Salvatori F, De Castro G, Guido CA, Zicari AM, Ciacci P, Battaglia S, Brindisi G, Ettorre E, Nocella C, Salvatori G, Duse M, Violi F, Carnevale R. Oxidative stress and gut-derived lipopolysaccharides in children affected by paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. BMC Pediatr 2020; 20:127. [PMID: 32188439 PMCID: PMC7079429 DOI: 10.1186/s12887-020-02026-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/11/2020] [Indexed: 12/15/2022] Open
Abstract
Background Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections syndrome (PANDAS) identifies patients with acute onset of obsessive-compulsive and tic disorders. The objective of this study was to evaluate serum NOX2 levels, as well as 8-iso-prostaglandin F2α (8-iso-PGF2α) and lipopolysaccharide (LPS) of PANDAS patients. Methods In this study we wanted to compare serum levels of soluble NOX2-dp (sNOX-2-dp), iso-PGF2α and LPS in 60 consecutive subjects, including 30 children affected by PANDAS and 30 controls (CT) matched for age and gender. Serum zonulin was used as intestinal permeability assay. Results Compared with CT, PANDAS children had increased serum levels of sNOX-2-dp, 8-iso-PGF2α and LPS. Bivariate analysis showed that serum sNOX2-dp was significantly correlated with LPS (Rs = 0.359; p = 0.005), zonulin (Rs = 0.444; p < 0.001) and 8-iso-PGF2α (Rs = 0.704; p < 0.001). Serum LPS significantly correlated with zonulin (Rs = 0.610; p < 0.001), and 8-iso-PGF2α (Rs = 0.591; p = 0.001). Finally, a multiple linear regression analysis showed that serum 8-iso-PGF2α and zonulin were the only independent variables associated with sNOX2-dp (R2 = 68%). Conclusion This study shows that children affected by PANDAS have high circulating levels of sNOX2-dp, isoprostanes and of LPS that could be involved in the process of neuroinflammation.
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Affiliation(s)
- Lorenzo Loffredo
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Alberto Spalice
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | | | - Giovanna De Castro
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | | | - Anna Maria Zicari
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | - Paolo Ciacci
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy
| | - Simona Battaglia
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy
| | - Giulia Brindisi
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | - Evaristo Ettorre
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy
| | - Cristina Nocella
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | | | - Marzia Duse
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | - Francesco Violi
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
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107
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Th17 lymphocytes drive vascular and neuronal deficits in a mouse model of postinfectious autoimmune encephalitis. Proc Natl Acad Sci U S A 2020; 117:6708-6716. [PMID: 32161123 DOI: 10.1073/pnas.1911097117] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Antibodies against neuronal receptors and synaptic proteins are associated with a group of ill-defined central nervous system (CNS) autoimmune diseases termed autoimmune encephalitides (AE), which are characterized by abrupt onset of seizures and/or movement and psychiatric symptoms. Basal ganglia encephalitis (BGE), representing a subset of AE syndromes, is triggered in children by repeated group A Streptococcus (GAS) infections that lead to neuropsychiatric symptoms. We have previously shown that multiple GAS infections of mice induce migration of Th17 lymphocytes from the nose into the brain, causing blood-brain barrier (BBB) breakdown, extravasation of autoantibodies into the CNS, and loss of excitatory synapses within the olfactory bulb (OB). Whether these pathologies induce functional olfactory deficits, and the mechanistic role of Th17 lymphocytes, is unknown. Here, we demonstrate that, whereas loss of excitatory synapses in the OB is transient after multiple GAS infections, functional deficits in odor processing persist. Moreover, mice lacking Th17 lymphocytes have reduced BBB leakage, microglial activation, and antibody infiltration into the CNS, and have their olfactory function partially restored. Th17 lymphocytes are therefore critical for selective CNS entry of autoantibodies, microglial activation, and neural circuit impairment during postinfectious BGE.
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108
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Szejko N, Fremer C, Sühs KW, Macul Ferreira de Barros P, Müller-Vahl KR. Intravenous Immunoglobulin Treatment Did Not Improve Tics in a Patient With Gilles de la Tourette Syndrome and Intrathecal Antibody Synthesis. Front Neurol 2020; 11:110. [PMID: 32180755 PMCID: PMC7059101 DOI: 10.3389/fneur.2020.00110] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/31/2020] [Indexed: 12/22/2022] Open
Abstract
Gilles de la Tourette syndrome (GTS) is a neuropsychiatric disorder characterized by motor and vocal tics. There are several hypotheses as to the cause of the disease. One of which suggests that the immune system is involved in the pathophysiology of GTS. Here, we present a 40-year-old female patient with a typical history and clinical presentation of GTS with tics and psychiatric comorbidities, in whom positive oligoclonal bands (OCBs) type 2 in cerebral spinal fluid (CSF) were detected in an earlier study. At that time point, all other investigations were unremarkable (including neurological examination and cMRI), but 2 years later, she presented with further neurological symptoms including tetraparesis mostly affecting the left limbs, distal hypesthesia and paresthesia, and dyspnea. Since further examinations (including EMG, MRI, CSF, virological, and bacteriological tests, as well as autoimmune-encephalitis antibodies) revealed normal results, based on clinical presentation, the diagnosis of Guillain-Barré-like immune-mediated neuropathy was made and treatment with intravenous immunoglobulins (IVIg) (30 g/day for 5 days) was initiated resulting in complete remission of immune-mediated neuropathy. Based on the “immune hypothesis” of GTS, we were interested in whether in this patient positive CSF OCBs might serve as a biomarker for treatment response of tics and additional GTS-related psychiatric symptoms to IVIg, and therefore assessed tics, premonitory urges, and psychiatric comorbidities before and several times after the IVIg treatment. However, even though immune-mediated neuropathy resolved after treatment, tics, premonitory urges, and comorbidities remained unchanged. Thus, this case study suggests that treatment with IVIg is not effective in the treatment of GTS—even in a patient with intrathecal antibody synthesis as expressed by CSF isolated OCBs.
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Affiliation(s)
- Natalia Szejko
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany.,Department of Bioethics, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Carolin Fremer
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | | | | | - Kirsten R Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
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109
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Baj J, Sitarz E, Forma A, Wróblewska K, Karakuła-Juchnowicz H. Alterations in the Nervous System and Gut Microbiota after β-Hemolytic Streptococcus Group A Infection-Characteristics and Diagnostic Criteria of PANDAS Recognition. Int J Mol Sci 2020; 21:E1476. [PMID: 32098238 PMCID: PMC7073132 DOI: 10.3390/ijms21041476] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
The objective of this paper is to review and summarize conclusions from the available literature regarding Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). The authors have independently reviewed articles from 1977 onwards, primarily focusing on the etiopathology, symptoms, differentiation between similar psychiatric conditions, immunological reactions, alterations in the nervous system and gut microbiota, genetics, and the available treatment for PANDAS. Recent research indicates that PANDAS patients show noticeable alterations within the structures of the central nervous system, including caudate, putamen, globus pallidus, and striatum, as well as bilateral and lentiform nuclei. Likewise, the presence of autoantibodies that interact with basal ganglia was observed in PANDAS patients. Several studies also suggest a relationship between the presence of obsessive-compulsive disorders like PANDAS and alterations to the gut microbiota. Further, genetic predispositions-including variations in the MBL gene and TNF-α-seem to be relevant regarding PANDAS syndrome. Even though the literature is still scarce, the authors have attempted to provide a thorough insight into the PANDAS syndrome, bearing in mind the diagnostic difficulties of this condition.
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Affiliation(s)
- Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-090 Lublin, Poland
| | - Elżbieta Sitarz
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (E.S.); (A.F.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (E.S.); (A.F.)
| | - Katarzyna Wróblewska
- North London Forensic Service, Chase Farm Hospital, 127 The Ridgeway, Enfield, Middlesex EN2 8JL, UK;
| | - Hanna Karakuła-Juchnowicz
- Chair and 1st Department of Psychiatry, Psychotherapy and Early Intervention, Medical University of Lublin, Gluska Street 1, 20-439 Lublin, Poland;
- Department of Clinical Neuropsychiatry, Medical University of Lublin, Gluska Street 1, 20-439 Lublin, Poland
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110
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Pape K, Tamouza R, Leboyer M, Zipp F. Immunoneuropsychiatry - novel perspectives on brain disorders. Nat Rev Neurol 2020; 15:317-328. [PMID: 30988501 DOI: 10.1038/s41582-019-0174-4] [Citation(s) in RCA: 267] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Immune processes have a vital role in CNS homeostasis, resilience and brain reserve. Our cognitive and social abilities rely on a highly sensitive and fine-tuned equilibrium of immune responses that involve both innate and adaptive immunity. Autoimmunity, chronic inflammation, infection and psychosocial stress can tip the scales towards disruption of higher-order networks. However, not only classical neuroinflammatory diseases, such as multiple sclerosis and autoimmune encephalitis, are caused by immune dysregulation that affects CNS function. Recent insight indicates that similar processes are involved in psychiatric diseases such as schizophrenia, autism spectrum disorder, bipolar disorder and depression. Pathways that are common to these disorders include microglial activation, pro-inflammatory cytokines, molecular mimicry, anti-neuronal autoantibodies, self-reactive T cells and disturbance of the blood-brain barrier. These discoveries challenge our traditional classification of neurological and psychiatric diseases. New clinical paths are required to identify subgroups of neuropsychiatric disorders that are phenotypically distinct but pathogenically related and to pave the way for mechanism-based immune treatments. Combined expertise from neurologists and psychiatrists will foster translation of these paths into clinical practice. The aim of this Review is to highlight outstanding findings that have transformed our understanding of neuropsychiatric diseases and to suggest new diagnostic and therapeutic criteria for the emerging field of immunoneuropsychiatry.
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Affiliation(s)
- Katrin Pape
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ryad Tamouza
- Inserm, U955, Institut Mondor de la Recherche Biomédicale, Créteil, France.,Fondation FondaMental, Créteil, France.,AP-HP, Department of Psychiatry of Mondor University Hospital, DHU PePsy, University of Paris-Est-Créteil, Créteil, France
| | - Marion Leboyer
- Inserm, U955, Institut Mondor de la Recherche Biomédicale, Créteil, France.,Fondation FondaMental, Créteil, France.,AP-HP, Department of Psychiatry of Mondor University Hospital, DHU PePsy, University of Paris-Est-Créteil, Créteil, France
| | - Frauke Zipp
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
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111
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Cabrera-Mendoza B, Genis-Mendoza AD, Nicolini H. Diagnosis in PANDAS: An Update. CURRENT PSYCHIATRY RESEARCH AND REVIEWS 2020. [DOI: 10.2174/2666082215666190917161514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:The last twenty years have seen major advancements in unraveling the etiology and the identification of biological markers of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci (PANDAS). However, this body of evidence has not yet been translated into a clinical setting.Objective:We will review the most important studies to date on PANDAS, emphasizing those whose advances could improve the diagnosis of these disorders. We also suggest the need for updated diagnosis criteria integrating the recent findings from the hereby included studies.Methods:Consulting the PubMed database, a literature review of the last twenty-one years (between 1998 and 2019) was carried out using the terms “PANDAS” and “pediatric autoimmune neuropsychiatric disorders” in combination with “diagnosis” and “markers”. The search resulted in 175 hits from which we selected clinical cases, original investigations, and clinical reviews.Results:This review offers a compilation of the most important studies performed to date regarding the clinical presentation and potential biological markers of PANDAS. Moreover, we suggest the refinement of some aspects in the current diagnosis criteria, such as focusing on specific symptoms and the inclusion of neuroimaging and peripheral markers.Conclusion:The identification of specific biological markers in PANDAS is crucial for its diagnosis and opportune treatment. Future research will determine whether PANDAS require separated diagnostic and therapeutic measures or if it should be included in recently proposed categories such as Pediatric Acute Neuropsychiatric Syndrome (PANS) or Childhood Acute Neuropsychiatric Syndrome (CANS).
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Affiliation(s)
- Brenda Cabrera-Mendoza
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, National Institute of Genomic Medicine (INMEGEN), CDMX, Mexico
| | - Alma Delia Genis-Mendoza
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, National Institute of Genomic Medicine (INMEGEN), CDMX, Mexico
| | - Humberto Nicolini
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, National Institute of Genomic Medicine (INMEGEN), CDMX, Mexico
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112
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Mataix-Cols D, Hansen B, Mattheisen M, Karlsson EK, Addington AM, Boberg J, Djurfeldt DR, Halvorsen M, Lichtenstein P, Solem S, Lindblad-Toh K, Haavik J, Kvale G, Rück C, Crowley JJ. Nordic OCD & Related Disorders Consortium: Rationale, design, and methods. Am J Med Genet B Neuropsychiatr Genet 2020; 183:38-50. [PMID: 31424634 PMCID: PMC6898732 DOI: 10.1002/ajmg.b.32756] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/19/2019] [Accepted: 07/29/2019] [Indexed: 12/23/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder, yet its etiology is unknown and treatment outcomes could be improved if biological targets could be identified. Unfortunately, genetic findings for OCD are lagging behind other psychiatric disorders. Thus, there is a pressing need to understand the causal mechanisms implicated in OCD in order to improve clinical outcomes and to reduce morbidity and societal costs. Specifically, there is a need for a large-scale, etiologically informative genetic study integrating genetic and environmental factors that presumably interact to cause the condition. The Nordic countries provide fertile ground for such a study, given their detailed population registers, national healthcare systems and active specialist clinics for OCD. We thus formed the Nordic OCD and Related Disorders Consortium (NORDiC, www.crowleylab.org/nordic), and with the support of NIMH and the Swedish Research Council, have begun to collect a large, richly phenotyped and genotyped sample of OCD cases. Our specific aims are geared toward answering a number of key questions regarding the biology, etiology, and treatment of OCD. This article describes and discusses the rationale, design, and methodology of NORDiC, including details on clinical measures and planned genomic analyses.
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Affiliation(s)
- David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Stockholm, Sweden
| | - Bjarne Hansen
- Haukeland University Hospital, OCD-team, Bergen, Norway,Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Manuel Mattheisen
- Department of Genomics, Life & Brain Center, University of Bonn, Bonn, Germany,Institute of Human Genetics, University of Bonn, Bonn, Germany,Center for Integrative Sequencing, iSEQ, Department of Biomedicine, Aarhus University, Denmark,Department of Psychiatry, Psychosomatics, and Psychotherapy, University of Würzburg, Germany
| | - Elinor K. Karlsson
- Broad Institute of MIT and Harvard, Cambridge, MA, USA,Program in Bioinformatics & Integrative Biology and Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Anjené M. Addington
- Genomics Research Branch, National Institute of Mental Health in Bethesda, Bethesda, Maryland, USA
| | - Julia Boberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Stockholm, Sweden
| | - Diana R. Djurfeldt
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Stockholm, Sweden
| | - Matthew Halvorsen
- Department of Genetics, University of North Carolina at Chapel Hill, NC, USA
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Stian Solem
- Haukeland University Hospital, OCD-team, Bergen, Norway,Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kerstin Lindblad-Toh
- Broad Institute of MIT and Harvard, Cambridge, MA, USA,Science for Life Laboratory, IMBIM, Uppsala University, Uppsala, Sweden
| | | | - Jan Haavik
- Department of Biomedicine, University of Bergen, Bergen, Norway,Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Gerd Kvale
- Haukeland University Hospital, OCD-team, Bergen, Norway,Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Christian Rück
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Stockholm, Sweden
| | - James J. Crowley
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Genetics, University of North Carolina at Chapel Hill, NC, USA,Department of Psychiatry, University of North Carolina at Chapel Hill, NC, USA
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113
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Piras C, Pintus R, Pruna D, Dessì A, Atzori L, Fanos V. Pediatric Acute-onset Neuropsychiatric Syndrome and Mycoplasma Pneumoniae Infection: A Case Report Analysis with a Metabolomics Approach. Curr Pediatr Rev 2020; 16:183-193. [PMID: 31642785 PMCID: PMC8193809 DOI: 10.2174/1573396315666191022102925] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/26/2019] [Accepted: 10/02/2019] [Indexed: 01/27/2023]
Abstract
Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinical condition characterized by a sudden and dramatic obsessive-compulsive disorder with a suggested post-infectious immune-mediated etiology. This condition is accompanied by an extensive series of relatively serious neuropsychiatric symptoms. The diagnosis of PANS is made by "exclusion", as the individual PANS symptoms overlap with a multiplicity of psychiatric disorders with the onset in childhood. A number of researchers accumulated evidence to support the hypothesis that PANS was closely associated with a number of infections. In the last decade, metabolomics played an essential role in improving the knowledge of complex biological systems and identifying potential new biomarkers as indicators of pathological progressions or pharmacologic responses to therapy. The metabolome is considered the most predictive phenotype, capable of recognizing epigenetic differences, reflecting more closely the clinical reality at any given moment and thus providing extremely dynamic data. In the present work, the most recent hypothesis and suggested mechanisms of this condition are reviewed and the case of a 10 - year-old girl with PANS is described, before and after clarithromycin treatment. The main results of this case report are discussed from a metabolomics point of view. The alteration of several metabolic pathways concerning the microbial activity highlights the possible role of the microbiome in the development of PANS. Furthermore, different metabolic perturbations at the level of protein biosynthesis, energy and amino acid metabolisms are observed and discussed. Based on our observations, it is believed that metabolomics is a promising technology to unravel the mysteries of PANS in the near future.
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Affiliation(s)
- Cristina Piras
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Roberta Pintus
- Department of Surgical Sciences, Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari, Italy
| | - Dario Pruna
- Pediatric Neurology and Epileptology Unit, Brotzu Hospital Trust, Cagliari, Italy
| | - Angelica Dessì
- Department of Surgical Sciences, Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari, Italy
| | - Luigi Atzori
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Vassilios Fanos
- Department of Surgical Sciences, Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari, Italy
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114
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Henderson TA, van Lierop MJ, McLean M, Uszler JM, Thornton JF, Siow YH, Pavel DG, Cardaci J, Cohen P. Functional Neuroimaging in Psychiatry-Aiding in Diagnosis and Guiding Treatment. What the American Psychiatric Association Does Not Know. Front Psychiatry 2020; 11:276. [PMID: 32351416 PMCID: PMC7176045 DOI: 10.3389/fpsyt.2020.00276] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/23/2020] [Indexed: 12/12/2022] Open
Abstract
While early efforts in psychiatry were focused on uncovering the neurobiological basis of psychiatric symptoms, they made little progress due to limited ability to observe the living brain. Today, we know a great deal about the workings of the brain; yet, none of this neurobiological awareness has translated into the practice of psychiatry. The categorical system which dominates psychiatric diagnosis and thinking fails to match up to the real world of genetics, sophisticated psychological testing, and neuroimaging. Nevertheless, the American Psychiatric Association (APA) recently published a position paper stating that neuroimaging provided no benefit to the diagnosis and treatment of psychiatric disorders. Using the diagnosis of depression as a model, we illustrate how setting aside the unrealistic expectation of a pathognomonic "fingerprint" for categorical diagnoses, we can avoid missing the biological and, therefore, treatable contributors to psychopathology which can and are visualized using functional neuroimaging. Infection, toxicity, inflammation, gut-brain dysregulation, and traumatic brain injury can all induce psychiatric manifestations which masquerade as depression and other psychiatric disorders. We review these and provide illustrative clinical examples. We further describe situations for which single photon emission computed tomography (SPECT) and positron emission tomography (PET) functional neuroimaging already meet or exceed the criteria set forth by the APA to define a neuroimaging biomarker, including the differential diagnosis of Alzheimer's disease and other dementias, the differential diagnosis of ADHD, and the evaluation of traumatic brain injury. The limitations, both real and perceived, of SPECT and PET functional neuroimaging in the field of psychiatry are also elaborated. An important overarching concept for diagnostic imaging in all its forms, including functional neuroimaging, is that imaging allows a clinician to eliminate possibilities, narrow the differential diagnosis, and tailor the treatment plan. This progression is central to any medical diagnostic process.
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Affiliation(s)
- Theodore A Henderson
- The Synaptic Space, Inc., Denver, CO, United States.,Neuro-Luminance, Inc., Denver, CO, United States.,Dr. Theodore Henderson, Inc., Denver, CO, United States.,International Society of Applied Neuroimaging, Denver, CO, United States
| | - Muriel J van Lierop
- International Society of Applied Neuroimaging, Denver, CO, United States.,Private Practice, Toronto, ON, Canada
| | - Mary McLean
- International Society of Applied Neuroimaging, Denver, CO, United States.,Private Practice, Toronto, ON, Canada
| | - John Michael Uszler
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Providence St. John's Health Center, Santa Monica, CA, United States.,Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, United States
| | - John F Thornton
- International Society of Applied Neuroimaging, Denver, CO, United States.,Rossiter-Thornton Associates, Toronto, ON, Canada
| | - Yin-Hui Siow
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Dan G Pavel
- International Society of Applied Neuroimaging, Denver, CO, United States.,PathFinder Brain SPECT, Deerfield, IL, United States
| | - Joe Cardaci
- International Society of Applied Neuroimaging, Denver, CO, United States.,Fremantle-School of Medicine, University of Notre Dame, Fremantle, WA, Australia.,Diagnostic Nuclear Medicine, Hollywood Private Hospital, Nedlands, WA, Australia.,Consultant Physician, Perth, WA, Australia
| | - Phil Cohen
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Lions Gate Hospital, Vancouver, BC, Canada.,Radiology, University of British Columbia, Vancouver, BC, Canada
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115
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Schlansky K, Facer B, Tanguturi YC, Cundiff AW, Fuchs DC. Pediatric Acute-Onset Neuropsychiatric Syndrome and Catatonia: A Case Report. PSYCHOSOMATICS 2020; 61:86-91. [PMID: 31079934 DOI: 10.1016/j.psym.2019.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 12/22/2022]
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116
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Farmer C, Thienemann M, Leibold C, Kamalani G, Sauls B, Frankovich J. Psychometric Evaluation of the Caregiver Burden Inventory in Children and Adolescents With PANS. J Pediatr Psychol 2019; 43:749-757. [PMID: 29547961 DOI: 10.1093/jpepsy/jsy014] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/25/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives To establish the psychometric properties of the Caregiver Burden Inventory (CBI) in patients with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), which is characterized by the abrupt onset of obsessive-compulsive disorder and/or restricted eating and at least two additional psychiatric symptoms. Parents of patients with PANS have reported high caregiver burden. However, no validated instrument of burden exists for this population. Methods Study took place at a community-based PANS clinic where the CBI is administered as part of routine clinical care. The first CBI available during an active disease flare was analyzed (N =104). Construct validity was evaluated within a confirmatory factor analytic framework. Associations between the CBI and patient/family characteristics were explored, and preliminary normative data for this population are presented. Results Item-factor loadings were strong, and the overall fit of the model was good (root mean square error of approximation = .061). Strict/metric measurement invariance was demonstrated across age. The mean Total Score in this sample was 36.72 ± 19.84 (interquartile range 19-53). Total Scores on the CBI were significantly elevated for parents of children who switched schools because of their illness (Cohen's d = 0.75, 95% confidence interval [CI] 0.28-1.22) and for those who had reduced work hours to accommodate the child's illness (Cohen's d = 0.65, 95% CI 0.10-1.20). However, in this relatively high-status sample, socioeconomic variables did not predict Total Scores. Conclusions Parents of patients with PANS experience high caregiver burden. The CBI may be confidently used to assess caregiver burden in this population.
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Affiliation(s)
- Cristan Farmer
- Intramural Research Program, National Institute of Mental Health
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine.,Child & Adolescent Psychiatry, Stanford University School of Medicine
| | - Collin Leibold
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine.,Pediatric Divisions of: Allergy, Immunology, & Rheumatology, Stanford University School of Medicine
| | | | - Bethany Sauls
- Intramural Research Program, National Institute of Mental Health
| | - Jennifer Frankovich
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine.,Pediatric Divisions of: Allergy, Immunology, & Rheumatology, Stanford University School of Medicine
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117
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 772] [Impact Index Per Article: 154.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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118
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Bamford NS, McVicar K. Localising movement disorders in childhood. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:917-928. [PMID: 31653548 DOI: 10.1016/s2352-4642(19)30330-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/22/2019] [Accepted: 09/16/2019] [Indexed: 12/16/2022]
Abstract
The diagnosis and management of movement disorders in children can be improved by understanding the pathways, neurons, ion channels, and receptors involved in motor learning and control. In this Review, we use a localisation approach to examine the anatomy, physiology, and circuitry of the basal ganglia and highlight the mechanisms that underlie some of the major movement disorders in children. We review the connections between the basal ganglia and the thalamus and cortex, address the basic clinical definitions of movement disorders, and then place diseases within an anatomical or physiological framework that highlights basal ganglia function. We discuss how new pharmacological, behavioural, and electrophysiological approaches might benefit children with movement disorders by modifying synaptic function. A better understanding of the mechanisms underlying movement disorders allows improved diagnostic and treatment decisions.
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Affiliation(s)
- Nigel S Bamford
- Departments of Pediatrics and Neurology, Yale University, New Haven, CT, USA; Department of Cellular and Molecular Physiology, Yale University, New Haven, CT, USA; Department of Neurology, University of Washington, Seattle, WA, USA.
| | - Kathryn McVicar
- Departments of Pediatrics and Neurology, Yale University, New Haven, CT, USA
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119
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Gromark C, Harris RA, Wickström R, Horne A, Silverberg-Mörse M, Serlachius E, Mataix-Cols D. Establishing a Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic: Baseline Clinical Features of the Pediatric Acute-Onset Neuropsychiatric Syndrome Cohort at Karolinska Institutet. J Child Adolesc Psychopharmacol 2019; 29:625-633. [PMID: 31170007 PMCID: PMC6786340 DOI: 10.1089/cap.2018.0127] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a descriptive clinical entity defined by the abrupt onset of psychiatric and somatic symptoms leading to significant loss of function. Data on well-characterized PANS patients are limited, biomarkers have yet to be identified, and a solid evidence base to guide treatment is lacking. In this study, we present our experience of a systematic evaluation of the first 45 patients included in a Swedish cohort. Methods: During the period 2014-2018, our clinic received 100 referrals regarding suspected PANS. All patients underwent a standardized psychiatric/medical evaluation by a child/adolescent psychiatrist and a clinical psychologist or a nurse. Those with severe symptoms were also assessed by a pediatric neurologist and a pediatric rheumatologist. Laboratory tests were obtained at different time points in an attempt to capture an active disease state. Results: Of the 100 referrals, 45 met strict PANS criteria and consented to participate in a long-term follow-up study. The median age at intake was 7.2 years (range 3.0-13.1) and 56% were male. Ninety-three percent fulfilled both criteria for acute/atypical onset of PANS symptoms and having had an infection in relation to onset. Sixteen percent had an onset of an autoimmune or inflammatory disorder in temporal relation to the onset of PANS-related symptoms. The most common onset symptoms were obsessive-compulsive disorder (89%), anxiety (78%), and emotional lability (71%). Twenty-four percent had a preexisting autoimmune disease (AD) and 18% a preexisting psychiatric/neuropsychiatric diagnosis. Sixty-four percent of biological relatives had at least one psychiatric disorder and 76% at least one AD or inflammatory disorder. Complement activation (37%), leukopenia (20%), positive antinuclear antibodies (17%), and elevated thyroid antibodies (11%) were the most common laboratory findings. Conclusions: In our PANS cohort, there was a strong indication of an association with AD. Further work is needed to establish whether any of the potential biomarkers identified will be clinically useful. Long-term follow-up of these patients using the Swedish national registers will enable a deeper understanding of the course of this patient group.
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Affiliation(s)
- Caroline Gromark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Robert A. Harris
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Neurology, Karolinska University Hospital, Solna, Sweden
| | - AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Rheumatology, Karolinska University Hospital, Solna, Sweden
| | - Maria Silverberg-Mörse
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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120
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Hesselmark E, Bejerot S. Patient Satisfaction and Treatments Offered to Swedish Patients with Suspected Pediatric Acute-Onset Neuropsychiatric Syndrome and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. J Child Adolesc Psychopharmacol 2019; 29:634-641. [PMID: 31009235 PMCID: PMC6786336 DOI: 10.1089/cap.2018.0141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are subtypes of Obsessive-Compulsive Disorder (OCD) with suggested autoimmune etiology. Immunomodulatory treatments have been introduced as treatment options. A recent systematic review concluded that the evidence for all treatment options for PANS and PANDAS is inconclusive. However, case reports and clinical experience suggest that antibiotics and immunomodulatory treatment may be helpful. Treatment may also affect the patients' satisfaction with health care services offered. This study aims to describe the treatments given to a cohort of Swedish patients with suspected PANS and PANDAS, the patient rated treatment effects, and to establish if any specific treatment predicts higher patient satisfaction. Methods: Fifty-three patients (m = 33, f = 20, median age = 14, age range = 4-36) with suspected PANS or PANDAS were enrolled and assessed for PANS and PANDAS caseness, treatments given, treatment effects, global improvement, and patient satisfaction. Cases with confirmed and suspected PANS or PANDAS were compared regarding the frequency of treatments given and treatment effect. A linear regression model was used to see if treatments given or global improvement predicted patient satisfaction. Results: Twenty-four participants fulfilled criteria for PANS or PANDAS and 29 did not. The most common treatments given were antibiotics (88%), nonsteroidal anti-inflammatory drugs (67%), cognitive behavioral therapy (53%), and selective serotonin reuptake inhibitors (42%). There were no major differences between confirmed and suspected cases regarding what treatments they had received or their effect. Patient satisfaction was predicted by overall clinical improvement at the time of assessment. Antibiotics and intravenous immunoglobulin (IVIG) were rated as the most successful treatments by participants and were associated with higher patient satisfaction. Conclusions: It was more common that patients had received antibiotics than common psychiatric treatments for their psychiatric symptoms. Antibiotics and IVIG were experienced as effective treatments by the patients. Patient satisfaction was on average moderately low, and higher patient satisfaction was associated with global clinical improvement.
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Affiliation(s)
- Eva Hesselmark
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Susanne Bejerot
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
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121
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Lepri G, Rigante D, Bellando Randone S, Meini A, Ferrari A, Tarantino G, Cunningham MW, Falcini F. Clinical-Serological Characterization and Treatment Outcome of a Large Cohort of Italian Children with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2019; 29:608-614. [PMID: 31140830 DOI: 10.1089/cap.2018.0151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: Pediatric autoimmune neuropsychiatric disorder associated with Streptococcus pyogenes infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are emerging immune-mediated encephalopathies characterized by sudden onset of seemingly inexplicable complex neuropsychiatric symptoms, including obsessions, compulsions, and heterogeneous tics, which occur in children. Main goal of this study was to report our experience in a large cohort of Italian children affected by either PANDAS or PANS and treated long term with an antibiotic regimen similar to that used for acute rheumatic fever. Patients and Methods: The clinical charts of a cohort of 371 consecutive Italian children, 345 with PANDAS (93.0%) and 26 with PANS (7.0%), were retrospectively evaluated. Antistreptococcal, antinuclear antibodies, and serologic evaluation for a group of common autoantibodies and microbial agents were also assessed. A strict differential diagnosis with other autoimmune diseases displaying neuropsychiatric manifestations was performed. Results: Antistreptolysin O and anti-DNase B antibody titers were tested and were positive in all PANDAS subjects, but negative in PANS. Anti-Mycoplasma pneumoniae antibodies and anti-Epstein-Barr virus Nuclear Antigen antibodies were found positive in 11 (42.3%) and 5 (19.2%) patients with PANS, respectively. Among PANDAS cases, a clear streptococcal infection was clinically evident at the onset of neurological symptoms in only 74 patients (21.4%), whereas the relationship with Streptococcus pyogenes was confirmed by serologic tests in the other 271 (78.6%). All patients fulfilling the diagnostic criteria for PANDAS (n = 345) received amoxicillin/clavulanic acid for 10-21 days at diagnosis, while those who were diagnosed with PANS (n = 26) received treatment according to the causative agent. Thereafter, all PANDAS/PANS patients received prophylaxis with benzathine benzylpenicillin for an overall period of at least 5 years to prevent subsequent potential streptococcal infections. To date, 75.0% of PANDAS patients (n = 258) have shown an improvement of neurologic symptoms, mainly observed within 3-5 months of treatment for PANDAS cases, while 88.4% of PANS patients (n = 23) have improved after 6-12 months. Infection-related relapses of neurologic manifestations were observed in both PANDAS and PANS patients (n = 167 out of 371; 45% of the total cohort) in the long term. Conclusions: Our study has confirmed the usefulness of the preliminary diagnostic criteria for PANDAS and PANS, revealing also the importance of early diagnosis to reduce the risk of evolution toward disabling chronic neurologic sequelae. Long-term antibiotic prophylaxis has resulted in a substantial benefit to reduce neurological symptoms for the majority of PANDAS and PANS patients over a 7-year period.
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Affiliation(s)
- Gemma Lepri
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Bellando Randone
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
| | - Antonella Meini
- Department of Pediatrics, Unit of Immunology and Pediatric Rheumatology, University of Brescia, Spedali Civili, Brescia, Italy
| | - Alessandra Ferrari
- Department of Pediatrics, Unit of Immunology and Pediatric Rheumatology, University of Brescia, Spedali Civili, Brescia, Italy
| | - Giusyda Tarantino
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy
| | - Madeleine W Cunningham
- Department of Microbiology and Immunology, Biomedical Research Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Fernanda Falcini
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
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Westwell-Roper C, Williams KA, Samuels J, Bienvenu OJ, Cullen B, Goes FS, Grados MA, Geller D, Greenberg BD, Knowles JA, Krasnow J, McLaughlin NC, Nestadt P, Shugart YY, Nestadt G, Stewart SE. Immune-Related Comorbidities in Childhood-Onset Obsessive Compulsive Disorder: Lifetime Prevalence in the Obsessive Compulsive Disorder Collaborative Genetics Association Study. J Child Adolesc Psychopharmacol 2019; 29:615-624. [PMID: 31170001 PMCID: PMC6786333 DOI: 10.1089/cap.2018.0140] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective: To evaluate the lifetime prevalence of infectious, inflammatory, and autoimmune disorders in a multisite study of probands with childhood-onset obsessive compulsive disorder (OCD) and their first-degree relatives. Methods: Medical questionnaires were completed by 1401 probands and 1045 first-degree relatives in the OCD Collaborative Genetics Association Study. Lifetime prevalence of immune-related diseases was compared with the highest available population estimate and reported as a point estimate with 95% adjusted Wald interval. Worst-episode OCD severity and symptom dimensions were assessed with the Yale-Brown Obsessive Compulsive Scale (YBOCS) and Symptom Checklist (YBOCS-CL). Results: Probands reported higher-than-expected prevalence of scarlet fever (4.0 [3.1-5.2]% vs. 1.0%-2.0%, z = 1.491, p < 0.001, n = 1389), encephalitis or meningitis (1.4 [0.9-2.1]% vs. 0.1%-0.4%, z = 5.913, p < 0.001, n = 1393), rheumatoid arthritis (1.1 [0.6-2.0]% vs. 0.2%-0.4%, z = 3.416, p < 0.001, n = 949) and rheumatic fever (0.6 [0.3-1.2]% vs. 0.1%-0.2%, z = 3.338, p < 0.001, n = 1390), but not systemic lupus erythematosus, diabetes, asthma, multiple sclerosis, psoriasis, or inflammatory bowel disease. First-degree relatives reported similarly elevated rates of scarlet fever, rheumatic fever, and encephalitis or meningitis independent of OCD status. There was no association between worst-episode severity and immune-related comorbidities, although probands reporting frequent ear or throat infections had increased severity of cleaning-/contamination-related symptoms (mean factor score 2.5 ± 0.9 vs. 2.3 ± 1.0, t = 3.183, p = 0.002, n = 822). Conclusion: These data suggest high rates of streptococcal-related and other immune-mediated diseases in patients with childhood-onset OCD and are consistent with epidemiological studies in adults noting familial clustering. Limitations include potential reporting bias and absence of a control group, underscoring the need for further prospective studies characterizing medical and psychiatric disease clusters and their interactions in children. Such studies may ultimately improve our understanding of OCD pathogenesis and aid in the development of adjunctive immune-modulating therapeutic strategies.
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Affiliation(s)
- Clara Westwell-Roper
- Department of Psychiatry, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kyle A. Williams
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Jack Samuels
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - O. Joseph Bienvenu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bernadette Cullen
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fernando S. Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marco A. Grados
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Geller
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Benjamin D. Greenberg
- Department of Psychiatry and Human Behavior, Brown Medical School, Butler Hospital, Providence, Rhode Island
| | - James A. Knowles
- Department of Psychiatry, University of Southern California School of Medicine, Los Angeles, California
| | - Janice Krasnow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicole C. McLaughlin
- Department of Psychiatry and Human Behavior, Brown Medical School, Butler Hospital, Providence, Rhode Island
| | - Paul Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yin-Yao Shugart
- Unit of Statistical Genomics, Division of Intramural Research, National Institute of Mental Health, Bethesda, Maryland
| | - Gerald Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - S. Evelyn Stewart
- Department of Psychiatry, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada.,Address correspondence to: S. Evelyn Stewart, MD, Department of Psychiatry, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Room A3-121, 950 West 28th Avenue, Vancouver, BC V5Z 4H4, Canada
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Abstract
OBJECTIVE An obsessive-compulsive disorder (OCD) subtype has been associated with streptococcal infections and is called pediatric autoimmune neuropsychiatric disorders associated with streptococci (PANDAS). The neuroanatomical characterization of subjects with this disorder is crucial for the better understanding of its pathophysiology; also, evaluation of these features as classifiers between patients and controls is relevant to determine potential biomarkers and useful in clinical diagnosis. This was the first multivariate pattern analysis (MVPA) study on an early-onset OCD subtype. METHODS Fourteen pediatric patients with PANDAS were paired with 14 healthy subjects and were scanned to obtain structural magnetic resonance images (MRI). We identified neuroanatomical differences between subjects with PANDAS and healthy controls using voxel-based morphometry, diffusion tensor imaging (DTI), and surface analysis. We investigated the usefulness of these neuroanatomical differences to classify patients with PANDAS using MVPA. RESULTS The pattern for the gray and white matter was significantly different between subjects with PANDAS and controls. Alterations emerged in the cortex, subcortex, and cerebellum. There were no significant group differences in DTI measures (fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity) or cortical features (thickness, sulci, volume, curvature, and gyrification). The overall accuracy of 75% was achieved using the gray matter features to classify patients with PANDAS and healthy controls. CONCLUSION The results of this integrative study allow a better understanding of the neural substrates in this OCD subtype, suggesting that the anatomical gray matter characteristics could have an immune origin that might be helpful in patient classification.
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Marazziti D, Albert U, Mucci F, Piccinni A. The Glutamate and the Immune Systems: New Targets for the Pharmacological Treatment of OCD. Curr Med Chem 2019; 25:5731-5738. [PMID: 29119912 DOI: 10.2174/0929867324666171108152035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/06/2017] [Accepted: 12/25/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND In the last decades the pharmacological treatment of obsessivecompulsive disorder (OCD) has been significantly promoted by the effectiveness of selective serotonin (5-HT) reuptake inhibitors (SSRIs) and the subsequent development of the 5-HT hypothesis of OCD. However, since a large majority of patients (between 40% and 60 %) do not respond to SSRIs or strategies based on the modulation of the 5-HT system, it is now essential to search for other possible therapeutic targets. AIMS The aim of this paper was to review current literature through a PubMed and Google Scholar search of novel hypotheses and related compounds for the treatment of OCD, with a special focus on the glutammate and the immune systems. DISCUSSION The literature indicates that glutamate, the main excitatory neurotransmitter, might play an important role in the pathophysiology of OCD. In addition, a series of clinical studies also supports the potential efficacy of drugs modulating the glutamate system. The role of the immune system alterations in OCD in both children and adults needs to be more deeply elucidated. In children, a subtype of OCD has been widely described resulting from infections driven by group A streptococcus β-hemolitic and belonging to the so-called "pediatric autoimmune neuropsychiatric disorders associated with streptococcus" (PANDAS). In adults, available findings are meager and controversial, although interesting. CONCLUSION The glutamate and the immune systems represent two intriguing topics of research that hold promise for the development of open novel treatment strategies in OCD.
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Affiliation(s)
- Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy
| | - Federico Mucci
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Armando Piccinni
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
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125
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Association of chronic and acute inflammation of the mucosa-associated lymphoid tissue with psychiatric disorders and suicidal behavior. Transl Psychiatry 2019; 9:227. [PMID: 31515504 PMCID: PMC6742630 DOI: 10.1038/s41398-019-0568-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/26/2019] [Accepted: 07/30/2019] [Indexed: 12/11/2022] Open
Abstract
Immune dysregulation due to chronic inflammation is a hypothesized risk factor underlying psychiatric disorders and suicidal behavior. Whether tonsillectomy and acute appendicitis used, respectively, as proxies for chronic and acute inflammation within the mucosa-associated lymphoid tissue (MALT) are associated with psychiatric disorders and suicidal behavior is currently unknown. A birth cohort study was conducted including 3,052,875 individuals born in Sweden between 1973 and 2003. We identified 210,686 individuals ever exposed to tonsillectomy and 86,928 individuals ever exposed to acute appendicitis, as well as 317,214 clusters of siblings discordant for tonsillectomy, and 160,079 sibling clusters discordant for acute appendicitis. Outcomes were an aggregate risk of 'any psychiatric disorder', 'any suicidal behavior', 12 individual psychiatric disorders, suicide attempts and deaths by suicide. Tonsillectomy was associated with increased odds of 'any psychiatric disorder' (adjusted odds ratio [aOR] = 1.39; 95% confidence interval (CI) = 1.38-1.41) and 'any suicidal behavior' (aOR = 1.41; 95% CI = 1.37-1.44), and most individual disorders. Acute appendicitis also increased the odds of 'any psychiatric disorder' and 'any suicidal behavior' (aOR = 1.23; 95% CI = 1.20-1.25, and aOR = 1.32; 95% CI = 1.28-1.37, respectively). Exposure to both tonsillectomy and appendicitis was associated with the highest odds of 'any psychiatric disorder' (aOR = 1.70; 95% CI = 1.59-1.82) and 'any suicidal behavior' (aOR = 1.90; 95% CI = 1.70-2.12). In sibling comparisons, the associations were attenuated but remained significant. We conclude that inflammation within the MALT, particularly when chronic, is robustly associated with a broad range of psychiatric disorders and suicidal behavior.
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126
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Khramtsova EA, Heldman R, Derks EM, Yu D, Davis LK, Stranger BE. Sex differences in the genetic architecture of obsessive-compulsive disorder. Am J Med Genet B Neuropsychiatr Genet 2019; 180:351-364. [PMID: 30456828 PMCID: PMC6527502 DOI: 10.1002/ajmg.b.32687] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/31/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a highly heritable complex phenotype that demonstrates sex differences in age of onset and clinical presentation, suggesting a possible sex difference in underlying genetic architecture. We present the first genome-wide characterization of the sex-specific genetic architecture of OCD, utilizing the largest set of OCD cases and controls available from the Psychiatric Genomics Consortium. We assessed evidence for several mechanisms that may contribute to sex differences including a sex-dependent liability threshold, the presence of individual sex-specific risk variants on the autosomes and the X chromosome, and sex-specific pleiotropic effects. Furthermore, we tested the hypothesis that genetic heterogeneity between the sexes may obscure associations in a sex-combined genome-wide association study. We observed a strong genetic correlation between male and female OCD and no evidence for a sex-dependent liability threshold model, suggesting that sex-combined analysis does not suffer from widespread loss of power because of genetic heterogeneity between the sexes. While we did not detect any significant sex-specific genome-wide single nucleotide polymorphisms (SNP) associations, we did identify two significant gene-based associations in females: GRID2 and GRP135, which showed no association in males. We observed that the SNPs with sexually differentiated effects showed an enrichment of regulatory variants influencing expression of genes in brain and immune tissues. These findings suggest that future studies with larger sample sizes hold great promise for the identification of sex-specific genetic risk factors for OCD.
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Affiliation(s)
- Ekaterina A Khramtsova
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- Institute for Genomics and Systems Biology, University of Chicago, Chicago, Illinois
| | | | - Eske M Derks
- Queensland Institute of Medical Research, Brisbane, Australia
| | - Dongmei Yu
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Lea K Davis
- Vanderbilt Genetics Institute; Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Medical Genetics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Barbara E Stranger
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- Institute for Genomics and Systems Biology, University of Chicago, Chicago, Illinois
- Center for Data Intensive Science, University of Chicago, Chicago, Illinois
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127
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Abstract
This review and commentary is the product of an invited lecture called "Autoimmunity: PANS/PANDAS" presented at the 2018 Neurobiology of Diseases in Children Symposium in Chicago, IL. The talk addressed clinical and scientific questions and recently published data. At this time, among highly experienced and respected clinicians and researchers spanning relevant disciplines, there is substantial controversy regarding a role for inflammation in producing tics and obsessive-compulsive disorder. This commentary summarizes these controversies, discusses reasons for opposing views on best clinical practices, and concludes with suggestions for pathways forward.
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Affiliation(s)
- Donald L. Gilbert
- Division of Neurology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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128
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11th International Congress on Psychopharmacology & 7th International Symposium on Child and Adolescent Psychopharmacology. PSYCHIAT CLIN PSYCH 2019. [DOI: 10.1080/24750573.2019.1606883] [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: 02/07/2023] Open
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129
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Abstract
PURPOSE OF REVIEW This article reviews current knowledge regarding diagnosis, pathophysiology, and treatment trends in obsessive-compulsive disorder (OCD), a severe, underrecognized, and chronic condition frequently encountered in neurologic practice. RECENT FINDINGS With a lifetime prevalence estimated at 2.5%, OCD is a common condition that can also present comorbidly with neurologic disease. The core symptoms of OCD are obsessions and compulsions. Obsessions are intrusive repetitive thoughts, urges, images, or impulses that trigger anxiety and that the individual is not able to suppress. Compulsions are repetitive behaviors or mental acts occurring in response to an obsession with the intention of reducing the distress caused by obsessions. Neuroimaging, neuropsychological, and pharmacologic studies suggest that the expression of OCD symptoms is associated with dysfunction in a cortico-striato-thalamo-cortical circuit. Evidence-based treatments for OCD comprise pharmacotherapy and cognitive-behavioral therapy. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs recommended for OCD, but significant differences exist in their use for OCD compared to their use for other mood and anxiety conditions, including the need for higher dosage, longer trials necessitated by a longer lag for therapeutic response, and typically lower response rates. Cognitive-behavioral therapy, based on the principles of exposure and response prevention, shows results superior to pharmacologic treatments with lower relapse rates on long-term follow-up and thus should be considered in the treatment plan of every patient with OCD. SUMMARY OCD and obsessive-compulsive symptoms are frequently encountered in the neurologic clinic setting and require a high index of suspicion to effectively screen for them and an illness-specific therapeutic approach.
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130
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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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131
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Breithaupt L, Köhler-Forsberg O, Larsen JT, Benros ME, Thornton LM, Bulik CM, Petersen L. Association of Exposure to Infections in Childhood With Risk of Eating Disorders in Adolescent Girls. JAMA Psychiatry 2019; 76:800-809. [PMID: 31017632 PMCID: PMC6487907 DOI: 10.1001/jamapsychiatry.2019.0297] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Infections are recognized as playing a critical role in the risk of psychiatric disorders and suicidal behavior; however, few studies have evaluated the risk of eating disorders. OBJECTIVE To evaluate the association of hospitalization for infections and treatment with anti-infective agents with the risk of an eating disorder diagnosis. DESIGN, SETTING, AND PARTICIPANTS A nationwide, population-based, prospective cohort study of 525 643 girls born from January 1, 1989, to December 31, 2006, and followed up until December 31, 2012, was conducted using individual-level data drawn from Danish longitudinal registers. Data were analyzed from January 15 to June 15, 2018, using survival analysis models and adjusted for age, calendar period, parental educational level, and parental history of psychiatric illness. EXPOSURES Hospital admission for infections and prescribed anti-infective agents for infections. MAIN OUTCOMES AND MEASURES The main outcome of interest was diagnosis of an eating disorder (anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified) in a hospital, outpatient clinic, or emergency department setting. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and accompanying 95% CIs. RESULTS The study population consisted of 525 643 adolescent girls: 2131 received a diagnosis of anorexia nervosa (median [range] age, 15.2 [8.6-21.3] years), 711 received a diagnosis of bulimia nervosa (median [range] age, 17.9 [13.4-22.7] years), and 1398 received a diagnosis of an eating disorder not otherwise specified (median [range] age, 15.6 [8.6-21.6] years). A total of 525 643 adolescent girls were followed up for 4 601 720.4 person-years until a mean age of 16.2 years (range, 10.5-22.7 years). Severe infections that required hospitalization were associated with an increased risk of a subsequent diagnosis of anorexia nervosa by 22% (HR, 1.22; 95% CI, 1.10-1.35), bulimia nervosa by 35% (HR, 1.35; 95% CI, 1.13-1.60), and eating disorder not otherwise specified by 39% (HR, 1.39; 95% CI, 1.23-1.57) compared with adolescent girls without hospitalizations for infections. Infections treated with anti-infective agents were associated with an increased risk of a subsequent diagnosis of anorexia nervosa by 23% (HR, 1.23; 95% CI, 1.10-1.37), bulimia nervosa by 63% (HR, 1.63; 95% CI, 1.32-2.02), and eating disorder not otherwise specified by 45% (HR, 1.45; 95% CI, 1.25-1.67) compared with adolescent girls without infections treated with anti-infective agents. CONCLUSIONS AND RELEVANCE The findings suggest that hospital-treated infections and less severe infections treated with anti-infective agents are associated with increased risk of subsequent anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified and that future studies should investigate whether these associations are causal and identify the exact mechanisms between infections and subsequent inflammatory processes with eating disorders.
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Affiliation(s)
- Lauren Breithaupt
- Department of Psychology, George Mason University, Fairfax, Virginia,Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital–Psychiatry, Risskov, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark,Centre for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Janne Tidselbak Larsen
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark,National Centre for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Michael E. Benros
- National Centre for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark,Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Laura Marie Thornton
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
| | - Cynthia M. Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Liselotte Petersen
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark,National Centre for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
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132
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Melerine C, Ledet LM. PANDAS: What nurses need to know. Nursing 2019; 49:46-49. [PMID: 31343533 DOI: 10.1097/01.nurse.0000559921.99814.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) describes a disorder that develops in children who abruptly develop neurologic abnormalities following a streptococcal infection. The authors discuss what is known about this poorly understood disorder and how nurses can educate and support patients and their families.
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Affiliation(s)
- Chelsea Melerine
- Chelsea Melerine is a recent BSN graduate of the honors program at LSU Health New Orleans School of Nursing in New Orleans, La., where Linda M. Ledet is an assistant professor of clinical nursing
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133
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Osman C, Jennings R, El-Ghariani K, Pinto A. Plasma exchange in neurological disease. Pract Neurol 2019; 20:92-99. [PMID: 31300488 DOI: 10.1136/practneurol-2019-002336] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 01/08/2023]
Abstract
Plasma exchange is a highly efficient technique to remove circulating autoantibodies and other humoral factors rapidly from the vascular compartment. It was the first effective acute treatment for peripheral disorders such as Guillain-Barré syndrome and myasthenia gravis before intravenous immunoglobulin became available. The recent recognition of rapidly progressive severe antibody-mediated central nervous system disorders, such as neuromyelitis optica spectrum disorders and anti-N-methyl-D-aspartate-receptor encephalitis, has renewed interest in using plasma exchange for their acute treatment also. In this review we explain the principles and technical aspects of plasma exchange, review its current indications, and discuss the implications for its provision in the UK.
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Affiliation(s)
- Chinar Osman
- Neurosciences, Wessex Neurological Centre, Southampton, UK
| | | | - Khaled El-Ghariani
- Therapeutics and Tissue Services, NHS Blood and Transplant, Sheffield Teaching Hospitals NHS Trust and the University of Sheffield, Sheffield, UK
| | - Ashwin Pinto
- Neurosciences, Wessex Neurological Centre, Southampton, UK
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134
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Baumgaertel C, Skripuletz T, Kronenberg J, Stangel M, Schwenkenbecher P, Sinke C, Müller-Vahl KR, Sühs KW. Immunity in Gilles de la Tourette-Syndrome: Results From a Cerebrospinal Fluid Study. Front Neurol 2019; 10:732. [PMID: 31333575 PMCID: PMC6621640 DOI: 10.3389/fneur.2019.00732] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Several lines of evidence support the hypothesis of an autoimmune origin of Gilles de la Tourette-Syndrome (GTS). Accordingly, in a recent study we detected positive oligoclonal bands (OCB) in cerebrospinal fluid (CSF) in >30% of adult patients indicating an intrathecal antibody synthesis. However, until today no corresponding antibodies could be identified. The aims of this study were to replicate our findings of positive OCB in an independent sample and to detect CSF autoantibodies. Methods: In this prospective study, 20 adult patients with GTS (male: female = 18:2, median age 36.1 years ± 14.34 SD) were included. All patients were thoroughly clinically characterized. Magnetic Resonance Imaging (MRI) and CSF standard measurements were performed. Isoelectric focusing on polyacrylamide gels with silver staining was used to detect OCB. To examine specific and unspecified autoantibodies, we used transfected Human Embryonic Kidney (HEK) cells expressing different surface antigens (NMDA-, CASPR2-, LGI1-, AMPA-, or GABAB1/B), indirect immunofluorescence on different brain tissue sections, and enzyme-linked visualization. Additionally, we differentiated Glioma stem cells SY5Y (human neuroblastoma) using retinoic acid and astrocytes (rat). Results: CSF analyses showed positive OCB (type 2) in 4/20 patients (20%). Using transfected HEK cells we did not find specific surface-autoantibodies. Immunohistochemistry on tissue-sections, SY5Y Glioma stem-cells, and astrocytes showed no specific binding patterns either. Conclusions: Our results corroborate previous findings and demonstrate positive OCB in a substantial number of patients with GTS (prevalence in healthy controls: 5%). Although this is the largest study investigating CSF autoantibodies in GTS using several techniques, we failed to detect any specific or unspecified autoantibodies.
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Affiliation(s)
- Charlotte Baumgaertel
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | | | - Jessica Kronenberg
- Department of Neurology, Hannover Medical School, Hanover, Germany.,Center for Systems Neuroscience, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hanover, Germany
| | | | - Christopher Sinke
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Kirsten R Müller-Vahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
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135
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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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136
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Rogers JP, Pollak TA, Blackman G, David AS. Catatonia and the immune system: a review. Lancet Psychiatry 2019; 6:620-630. [PMID: 31196793 PMCID: PMC7185541 DOI: 10.1016/s2215-0366(19)30190-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 03/27/2019] [Accepted: 04/04/2019] [Indexed: 12/13/2022]
Abstract
Catatonia is a psychomotor disorder featuring stupor, posturing, and echophenomena. This Series paper examines the evidence for immune dysregulation in catatonia. Activation of the innate immune system is associated with mutism, withdrawal, and psychomotor retardation, which constitute the neurovegetative features of catatonia. Evidence is sparse and conflicting for acute-phase activation in catatonia, and whether this feature is secondary to immobility is unclear. Various viral, bacterial, and parasitic infections have been associated with catatonia, but it is primarily linked to CNS infections. The most common cause of autoimmune catatonia is N-methyl-D-aspartate receptor (NMDAR) encephalitis, which can account for the full spectrum of catatonic features. Autoimmunity appears to cause catatonia less by systemic inflammation than by the downstream effects of specific actions on extracellular antigens. The specific association with NMDAR encephalitis supports a hypothesis of glutamatergic hypofunction in catatonia.
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Affiliation(s)
- Jonathan P Rogers
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, UK.
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, UK
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
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137
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Guido CA, Zicari AM, Duse M, Spalice A. Eye movement desensitisation and reprocessing (EMDR) treatment associated with parent management training (PMT) for the acute symptoms in a patient with PANDAS syndrome: a case report. Ital J Pediatr 2019; 45:74. [PMID: 31242942 PMCID: PMC6595549 DOI: 10.1186/s13052-019-0667-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022] Open
Abstract
Background The purpose of this report was to present the results of eye movement desensitisation and reprocessing (EMDR) therapy associated with parent management training (PMT) in a child with paediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS), who had previously only been treated with pharmacological treatment. Case presentation The case concerns an 11-year-old boy who presented with simple and complex vocal tics, motor tics, obsessive-compulsive traits and irritability from the age of 6 years, in addition to a positive result for streptococcal infection. The course of symptoms followed a relapsing-remitting trend with acute phases that were contingent on the infectious episodes. Conclusions Following eight sessions of EMDR, preceded by training sessions with the parents, the child showed a significant reduction in symptoms and disappearance of the exacerbation. These results indicate the possibility of improving the treatment outcomes of patients with PANDAS by a combined approach using both antibiotic and EMDR therapies.
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Affiliation(s)
- Cristiana A Guido
- Department of Pediatrics, Child Neurology Division, Sapienza University of Rome, 00161, Rome, Italy
| | - Anna Maria Zicari
- Department of Pediatrics, Pediatric Division, Sapienza University of Rome, 00161, Rome, Italy
| | - Marzia Duse
- Department of Pediatrics, Pediatric Division, Sapienza University of Rome, 00161, Rome, Italy
| | - Alberto Spalice
- Department of Pediatrics, Child Neurology Division, Sapienza University of Rome, 00161, Rome, Italy.
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138
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Changes in gut microbiota during development of compulsive checking and locomotor sensitization induced by chronic treatment with the dopamine agonist quinpirole. Behav Pharmacol 2019; 29:211-224. [PMID: 29194070 DOI: 10.1097/fbp.0000000000000363] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Long-term treatment of rats with the D2/D3 dopamine agonist quinpirole induces compulsive checking (proposed as animal model of obsessive-compulsive disorder) and locomotor sensitization. The mechanisms by which long-term use of quinpirole produces those behavioral transformations are not known. Here we examined whether changes in gut microbiota play a role in these behavioral phenomena, by monitoring the development of compulsive checking and locomotor sensitization at the same time as measuring the response of gut microbiota to chronic quinpirole injections. Two groups of rats received nine injections of saline (n=16) or quinpirole (n=15; 0.25 mg/kg), at weekly intervals for the first 5 weeks and then two injections per week until the end of treatment. After each injection, rats were placed on a large open field for 55 min, and their behavior was video recorded for subsequent analysis. Fecal matter was collected after each trial and frozen for bacterial community profiling of the 16S rRNA gene, using paired-end reads of the V3 region. The results indicated that the induction of locomotor sensitization and compulsive checking was accompanied by changes in several communities of bacteria belonging to the order Clostridiales (class Clostridia, phylum Firmicutes), and predominantly in Lachnospiraceae and Ruminococcaceae families of bacteria. It is suggested that changes in these microbes may serve to support the energy use requirements of compulsive checking and obsessive-compulsive disorder.
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139
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Gogos A, Federle MJ. Modeling Streptococcus pyogenes Pharyngeal Colonization in the Mouse. Front Cell Infect Microbiol 2019; 9:137. [PMID: 31119108 PMCID: PMC6507483 DOI: 10.3389/fcimb.2019.00137] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022] Open
Abstract
Streptococcus pyogenes, or Group A Streptococcus (GAS), is a human-restricted pathogen most commonly found in the posterior oropharynx of the human host. The bacterium is responsible for 600 million annual cases of pharyngitis globally and has been found to asymptomatically colonize the pharynxes of 4-30% of the population. As such, many studies have utilized animals as models in order to decipher bacterial and host elements that contribute to the bacterial-pharyngeal interaction and determine differences between acute infection and asymptomatic colonization. The aim of this review is to first describe both bacterial and host factors that are important for the pharyngeal persistence of GAS in humans, then to detail the bacterial and host factors that are important for colonization in murine model, and finally to compare the two in order to evaluate the strength of murine pharyngeal colonization as a model for the human-GAS pharyngeal interaction.
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Affiliation(s)
- Artemis Gogos
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, IL, United States
| | - Michael J. Federle
- Department of Medicinal Chemistry and Pharmacognosy, Center for Biomolecular Sciences, University of Illinois at Chicago, Chicago, IL, United States
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140
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Gamucci A, Uccella S, Sciarretta L, D'Apruzzo M, Calevo MG, Mancardi MM, Veneselli E, De Grandis E. PANDAS and PANS: Clinical, Neuropsychological, and Biological Characterization of a Monocentric Series of Patients and Proposal for a Diagnostic Protocol. J Child Adolesc Psychopharmacol 2019; 29:305-312. [PMID: 30724577 DOI: 10.1089/cap.2018.0087] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: Whether PANS (pediatric acute-onset neuropsychiatric syndrome) and PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) represent true clinical entities is debated and data for a characteristic phenotype are still controversial. In this study, we aim to characterize clinical, neuropsychological, and biochemical aspects in a sample of PANS and PANDAS patients. Methods: Patients fulfilling a clinical diagnosis of PANS or PANDAS from 2014 to 2017 were enrolled. Neurological and psychiatric examination and biochemical and instrumental assessment results were collected. A neuropsychological battery was administered. For comparison purposes, a control group of patients with Sydenham's chorea (SC) was evaluated. Descriptive and comparative statistical analyses were performed. Results: Seven subjects received a diagnosis of PANS, 12 of PANDAS, and 11 of SC. Clinical presentation of PANS children showed statistically significant differences compared with both PANDAS and SC, in particular, with the presence of obsessive symptoms, behavioral regression, and somatic symptoms in the first group. Moreover, all PANS patients showed some neuropsychological deficits in visual-motor abilities, short- and long-term memory, and processing speed. Conclusions: Our experience confirms that patients with PANS had a complex clinical presentation and a compromised neuropsychological profile with respect to patients with PANDAS or SC. However, the absence of biological markers or instrumental alterations made the diagnosis of the two entities, PANS and PANDAS, a matter of exclusion. For these reasons, we propose a pilot diagnostic protocol that (when applied in a prospective manner) will allow comparison with similar childhood-onset neuropsychiatric disorders, such as obsessive-compulsive or tic disorders, and efficacy evaluation of different therapeutic approaches.
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Affiliation(s)
- Alessandra Gamucci
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Sara Uccella
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Lucia Sciarretta
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Maria D'Apruzzo
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Maria Grazia Calevo
- 2 Epidemiology, Biostatistics and Committees Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Margherita Mancardi
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Edvige Veneselli
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Elisa De Grandis
- 1 Child Neuropsychiatry Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Children's Sciences, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
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141
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Williams K, Shorser-Gentile L, Sarvode Mothi S, Berman N, Pasternack M, Geller D, Walter J. Immunoglobulin A Dysgammaglobulinemia Is Associated with Pediatric-Onset Obsessive-Compulsive Disorder. J Child Adolesc Psychopharmacol 2019; 29:268-275. [PMID: 30892924 PMCID: PMC7227412 DOI: 10.1089/cap.2018.0043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Inflammation and immune dysregulation have been implicated in the pathogenesis of pediatric-onset obsessive-compulsive disorder (OCD) and tic disorders such as Tourette syndrome (TS). Though few replicated studies have identified markers of immune dysfunction in this population, preliminary studies suggest that serum immunoglobulin A (IgA) concentrations may be abnormal in these children with these disorders. Methods: This observational retrospective cohort study, conducted using electronic health records (EHRs), identified 206 children with pediatric-onset OCD and 1024 adults diagnosed with OCD who also had testing for serum levels of IgA. IgA deficiency and serum IgA levels in pediatric OCD were compared with IgA levels from children diagnosed with autism spectrum disorders (ASD; n = 524), tic disorders (n = 157), attention-deficit/hyperactivity disorder (ADHD; n = 534), anxiety disorders (n = 1206), and celiac disease, a condition associated with IgA deficiency (n = 624). Results: Compared with ASD and anxiety disorder cohorts, the pediatric OCD cohort displayed a significantly higher likelihood of IgA deficiency (OR = 1.93; 95% CI = 1.18-3.16, and OR = 1.98; 95% CI = 1.28-3.06, respectively), though no difference was observed between pediatric OCD and TS cohorts. Furthermore, the pediatric OCD cohort displayed similar rates of IgA deficiency and serum IgA levels when compared with the celiac disease cohort. The pediatric OCD cohort also displayed the highest percentage of IgA deficiency (15%,) when compared with TS (14%), celiac disease (14%), ADHD (13%), ASD (8%), and anxiety disorder (8%) cohorts. When segregated by sex, boys with OCD displayed a significantly higher likelihood of IgA deficiency when compared with all comparison cohorts except for celiac disease and tic disorders; no significant difference in IgA deficiency was observed between female cohorts. Pediatric OCD subjects also displayed significantly lower adjusted serum IgA levels than the ASD and anxiety disorder cohorts. Adults with OCD were also significantly less likely than children with OCD to display IgA deficiency (OR = 2.71; 95% CI = 1.71-4.28). When compared with children with celiac disease, no significant difference in IgA levels or rates of IgA deficiency were observed in the pediatric OCD cohort. Conclusions: We provide further evidence of IgA abnormalities in pediatric-onset OCD. These results require further investigation to determine if these abnormalities impact the clinical course of OCD in children.
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Affiliation(s)
- Kyle Williams
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.,Address correspondence to: Kyle Williams, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Simches Research Building, Suite 2000, 185 Cambridge Street, Boston, MA 02114
| | | | - Suraj Sarvode Mothi
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Noah Berman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark Pasternack
- Pediatric Infectious Disease Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel Geller
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Jolan Walter
- Allergy, Immunology, and Infectious Disease Program, University of South Florida, St. Petersburg, Florida
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142
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Wang LY, Chen SF, Chiang JH, Hsu CY, Shen YC. Systemic autoimmune diseases are associated with an increased risk of obsessive-compulsive disorder: a nationwide population-based cohort study. Soc Psychiatry Psychiatr Epidemiol 2019; 54:507-516. [PMID: 30406283 DOI: 10.1007/s00127-018-1622-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Studies suggested autoimmunity plays a role in the etiology of obsessive-compulsive disorder (OCD). The purpose of this study was to determine if a history of systemic autoimmune diseases (SADs) is associated with an increased risk of subsequent onset of OCD. METHODS Patients with or without SADs were identified in the Taiwan National Health Insurance Program. The SADs cohort consisted of 63,165, while the comparison cohort consisted of 315,825 patients. The incidence rates of OCD with a maximum follow-up period of 10 years between patients with and without SADs were compared using a Cox proportional hazard model to estimate the hazard ratio (HR) and 95% confidence interval (95% CI). RESULTS The major finding was the discovery of a higher incidence of subsequent OCD among patients with SADs (HR: 1.85; 95% CI 1.41-2.43) after adjusted for other demographic characteristics. Specifically, the risk of OCD was observed to be significant increase in systemic lupus erythematosus (1.65, 1.07-2.54) dermatomyositis (3.25, 1.04-10.17), and Sjögren's syndrome (2.38, 1.53-3.72). Also, this study revealed some potential risk factors for developing OCD, including younger age (less than or equal to 50-year-old) and some comorbidities (alcohol use disorder, liver cirrhosis, and malignancies). Conversely, this study found that steroid use was a potential protective factor for the development of OCD. CONCLUSIONS This study confirms that SADs are associated with higher incidence of OCD, suggesting that abnormal autoimmune process is associated with increased expression of psychiatric disturbances.
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Affiliation(s)
- Ling-Yi Wang
- Epidemiology and Biostatistics Consulting Center, Departments of Medical Research and Pharmacy, Tzu Chi General Hospital, Hualien, Taiwan
| | - Shih-Fen Chen
- Center of Medical Genetics, Tzu Chi General Hospital, Hualien, Taiwan
| | - Jen-Huai Chiang
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Chung-Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Yu-Chih Shen
- Department of Psychiatry, Tzu Chi General Hospital, 707, Sec. 3, Chung Yang Rd, Hualien, 970, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, Taiwan.
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143
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Early intervention for obsessive compulsive disorder: An expert consensus statement. Eur Neuropsychopharmacol 2019; 29:549-565. [PMID: 30773387 DOI: 10.1016/j.euroneuro.2019.02.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 01/04/2019] [Accepted: 02/02/2019] [Indexed: 12/29/2022]
Abstract
Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the 'toxic' effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.
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144
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Karacaoğlan G, Lüleyap Ü, Tahiroğlu AY, Pazarcı P, Yaman A, Çetiner S, Sertdemir Y, Lüleyap D. Streptokok enfeksiyonu ile ilişkili pediatrik otoimmün nöropsikiyatrik hastalık (PANDAS) ile insan lököksit antijen (HLA) ilişkisi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.426378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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145
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Heavey E, Peterson K. Treating pediatric acute-onset neuropsychiatric syndrome. Nurse Pract 2019; 44:44-49. [PMID: 30789532 DOI: 10.1097/01.npr.0000553400.88847.5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) can be caused by infectious and noninfectious triggers. NPs can help children with PANS recover from their symptoms and prevent future recurrences by appropriately screening, recognizing, and diagnosing the clinical presentation of PANS. PANS treatment includes pharmacologic therapies as well as cognitive behavioral therapy.
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Affiliation(s)
- Elizabeth Heavey
- Elizabeth Heavey is a professor of nursing and graduate program director at The College at Brockport, Brockport, N.Y. Heavey is also a certified nurse-midwife. Kathleen Peterson is a professor of nursing and chair of the department of nursing at The College at Brockport, Brockport, N.Y. Peterson is also a certified pediatric NP
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146
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Hesselmark E, Bejerot S. Clinical features of paediatric acute-onset neuropsychiatric syndrome: findings from a case- control study. BJPsych Open 2019; 5:e25. [PMID: 31068234 PMCID: PMC6401534 DOI: 10.1192/bjo.2019.10] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Paediatric acute-onset neuropsychiatric syndrome (PANS), an umbrella term that includes PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is suggested to be a psychiatric disorder of autoimmune aetiology. PANS is characterised by an acute onset of obsessive-compulsive disorder or restricted eating with multiple comorbid symptoms. The specificity of the PANS criteria is not fully understood.AimsTo describe a cohort of patients with PANS and to determine if PANS features relating to symptoms, onset and course are more common in PANS than in other psychiatric conditions. METHOD A case-control study comparing patients with interview-confirmed PANS with patients with suspected PANS and patients with a psychiatric condition but with no suspicion of PANS. Validated and non-validated measures of symptoms, onset and episodic course were used. RESULTS Illness in patients with interview-confirmed PANS featured an episodic course and multiple symptoms present at onset compared with the psychiatric controls. However, individuals with interview-confirmed PANS did not present a specific symptom profile. CONCLUSIONS PANS may be a distinct clinical entity featuring an acute onset, an episodic course and multiple symptoms at onset.Declaration of interestNone.
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Affiliation(s)
- Eva Hesselmark
- PhD Student, Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet; and Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Susanne Bejerot
- Professor, School of Medical Sciences, Örebro University; University Health Care Research Center, Faculty of Medicine and Health, Örebro University; and Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Sweden
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147
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Silverman M, Frankovich J, Nguyen E, Leibold C, Yoon J, Mark Freeman G, Karpel H, Thienemann M. Psychotic symptoms in youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) may reflect syndrome severity and heterogeneity. J Psychiatr Res 2019; 110:93-102. [PMID: 30605785 DOI: 10.1016/j.jpsychires.2018.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/04/2018] [Accepted: 11/13/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE In the clinical syndrome Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), obsessive compulsive disorder (OCD) and/or food refusal symptoms have an abrupt-onset (over 48 h) coupled with at least two other specified neuropsychiatric symptoms. We aimed to characterize in detail for the first time, psychotic symptoms experienced by children with PANS as well as the impact of psychotic symptoms on disease severity and course of illness. We inform about the diagnosis of the clinical description: PANS and hope to improve evaluation, treatment, diagnostic validity and future investigation. METHODS Retrospective review of 143 consecutive PANS clinic patient charts meeting inclusion criteria. The Caregiver Burden Inventory, Global Impairment Score, and Children's Global Assessment Scale were used to assess impairment. RESULTS Visual and auditory hallucinations were each experienced by 36%, of which most (83%) were transient and complex (non-threatening voices or figures). 6.3% and 5.5% of patients experienced delusions and thought disorganization respectively. Those with psychotic symptoms showed statistically significant differences in disease impairment and caregiver burden. There were no differences in time to treatment access or length of illness. CONCLUSIONS Over 1/3 of children with PANS experienced transient hallucinations. They were more impaired than those without psychotic symptoms, but showed no differences in disease progression. This difference may point toward heterogeneity in PANS. When evaluating children with acute psychotic symptoms, clinicians should screen for abrupt-onset of a symptom cluster including OCD and/or food refusal, with neuropsychiatric symptoms (enuresis, handwriting changes, tics, hyperactivity, sleep disorder) before initiating treatment.
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Affiliation(s)
- Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States.
| | - Jennifer Frankovich
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Emily Nguyen
- Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Collin Leibold
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Jong Yoon
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; VA Palo Alto Health Care System, 3801 Miranda Ave., Building 4, 2nd Floor, Palo Alto, CA, 94304, United States
| | - G Mark Freeman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | - Hannah Karpel
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
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148
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Williams KA. Defining paediatric acute-onset neuropsychiatric syndrome. THE LANCET. CHILD & ADOLESCENT HEALTH 2019; 3:134-135. [PMID: 30704876 DOI: 10.1016/s2352-4642(19)30021-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 06/09/2023]
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149
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Leibold C, Thienemann M, Farhadian B, Willett T, Frankovich J. Psychometric Properties of the Pediatric Acute-Onset Neuropsychiatric Syndrome Global Impairment Score in Children and Adolescents with Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2019; 29:41-49. [PMID: 30421965 DOI: 10.1089/cap.2018.0029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study validates the caregiver-rated Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) Global Impairment Score (GIS), a single-item, 0-100 scale, for use in PANS. METHODS We collected longitudinal data from community patients meeting PANS criteria. We included 128 patients with 1926 GISs, each from a unique clinic visit. To assess discriminant validity, we compared GISs from patients with PANS with scores from a population of healthy controls. To evaluate external validity, we compared global impairment with a clinician-reported global measure-the Child Global Assessment Scale (CGAS)-using the Bland-Altman plots and correlation coefficients. Then, we evaluated associations between the PANS GIS and symptom-specific disease severity variables by fitting mixed models with repeated measures. RESULTS The GIS shows excellent discriminant validity, distinguishing patients with PANS from healthy controls. The scores on the GIS show an acceptable level of agreement with the clinician-reported CGAS. The regression line in the Bland-Altman plot had a positive slope, indicating that parents tend to report higher disease severity than clinicians at higher levels of disease severity. Correlation was higher during disease remissions than during disease flares (r = -0.69 vs. r = -0.48). All disease severity scales predicted GIS in the expected direction. CONCLUSION The GIS has excellent discriminant validity and acceptable construct validity.
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Affiliation(s)
- Collin Leibold
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California
| | - Margo Thienemann
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,2 Child and Adolescent Psychiatry, Stanford University School of Medicine , Palo Alto, California
| | - Bahare Farhadian
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,3 Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine , Palo Alto, California
| | - Theresa Willett
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,3 Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine , Palo Alto, California
| | - Jennifer Frankovich
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,3 Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine , Palo Alto, California
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150
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Bejerot S, Hesselmark E, Mobarrez F, Wallén H, Hietala MA, Nybom R, Wetterberg L. Neuromyelitis optica spectrum disorder with increased aquaporin-4 microparticles prior to autoantibodies in cerebrospinal fluid: a case report. J Med Case Rep 2019; 13:27. [PMID: 30696485 PMCID: PMC6352324 DOI: 10.1186/s13256-018-1929-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/18/2018] [Indexed: 11/15/2022] Open
Abstract
Background Neuromyelitis optica spectrum disorders are severe autoimmune inflammatory diseases of the central nervous system associated with the presence of immunoglobulin G antibodies against the water channel protein aquaporin-4. During exacerbation, specific aquaporin-4 immunoglobulin G may be produced intrathecally. We measured extracellular aquaporin-4 microparticles in the cerebrospinal fluid of a patient who later developed the typical symptoms and signs of a neuromyelitis optica spectrum disorder. Case presentation A 17-year-old South American girl developed acute severe motor and vocal tics and difficulties in walking, peripheral numbness, muscle pain, and bilateral headache. At age 22, she had a multitude of motor and psychiatric symptoms. Over the years, she fulfilled the diagnostic criteria for anorexia nervosa, depression, sleep disorder, obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, agoraphobia, social anxiety disorder, development coordination disorder, attention-deficit/hyperactivity disorder, hypomania, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, conversion disorder, psychosis, and schizotypal personality syndrome. At age 24, she was found to have elevated titers of aquaporin-4 antibodies in serum, suggestive of probable neuromyelitis optica. She subsequently developed visual impairment, and swollen optic nerves were verified by magnetic resonance imaging. She was thus treated with a chimeric monoclonal antibody targeted against the pan-B-cell marker CD20 (rituximab), and almost all symptoms, including the psychiatric symptoms, rapidly decreased. We found a significant increase of extracellular microparticles of aquaporin-4 in cerebrospinal fluid sampled from our patient when she was 22 years old, 2 years before the full clinical development of neuromyelitis optica. Conclusions Microparticles of aquaporin-4 represent subcellular arrangements that may influence the pathogenesis of neuromyelitis optica spectrum disorders and may serve as biomarkers for the underlying cellular disturbances. The increase of aquaporin-4 microparticles in cerebrospinal fluid may be used for early diagnostic purposes; for prevention; and for evaluation of effective treatment, long-term follow-up studies, and elucidating the pathophysiology in neuromyelitis optica spectrum disorders. Further studies of aquaporin-4 microparticles in cerebrospinal fluid of patients with neuromyelitis optica and similar neuropsychiatric disorders are thus called for. Electronic supplementary material The online version of this article (10.1186/s13256-018-1929-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Susanne Bejerot
- Department of Clinical Neuroscience, Karolinska Institutet, SE-112 81, Stockholm, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden.,Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - Eva Hesselmark
- Department of Clinical Neuroscience, Karolinska Institutet, SE-112 81, Stockholm, Sweden
| | - Fariborz Mobarrez
- Unit of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Håkan Wallén
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Max Albert Hietala
- Department of Clinical Neuroscience, Karolinska Institutet, SE-112 81, Stockholm, Sweden
| | - Rolf Nybom
- Department of Clinical Neuroscience, Karolinska Institutet, SE-112 81, Stockholm, Sweden
| | - Lennart Wetterberg
- Department of Clinical Neuroscience, Karolinska Institutet, SE-112 81, Stockholm, Sweden.
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