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Eyre M, Thomas T, Ferrarin E, Khamis S, Zuberi SM, Sie A, Newlove-Delgado T, Morton M, Molteni E, Dale RC, Lim M, Nosadini M. Treatments and Outcomes Among Patients with Sydenham Chorea: A Meta-Analysis. JAMA Netw Open 2024; 7:e246792. [PMID: 38625703 PMCID: PMC11022117 DOI: 10.1001/jamanetworkopen.2024.6792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/17/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Sydenham chorea is the most common acquired chorea of childhood worldwide; however, treatment is limited by a lack of high-quality evidence. Objectives To evaluate historical changes in the clinical characteristics of Sydenham chorea and identify clinical and treatment factors at disease onset associated with chorea duration, relapsing disease course, and functional outcome. Data Sources The systematic search for this meta-analysis was conducted in PubMed, Embase, CINAHL, Cochrane Library, and LILACS databases and registers of clinical trials from inception to November 1, 2022 (search terms: [Sydenham OR Sydenham's OR rheumatic OR minor] AND chorea). Study Selection Published articles that included patients with a final diagnosis of Sydenham chorea (in selected languages). Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Individual patient data on clinical characteristics, treatments, chorea duration, relapse, and final outcome were extracted. Data from patients in the modern era (1945 through 2022) were entered into multivariable models and stratified by corticosteroid duration for survival analysis of chorea duration. Main Outcomes and Measures The planned study outcomes were chorea duration at onset, monophasic course (absence of relapse after ≥24 months), and functional outcome (poor: modified Rankin Scale score 2-6 or persisting chorea, psychiatric, or behavioral symptoms at final follow-up after ≥6 months; good: modified Rankin Scale score 0-1 and no chorea, psychiatric, or behavioral symptoms at final follow-up). Results In total, 1479 patients were included (from 307 articles), 1325 since 1945 (median [IQR] age at onset, 10 [8-13] years; 875 of 1272 female [68.8%]). Immunotherapy was associated with shorter chorea duration (hazard ratio for chorea resolution, 1.51 [95% CI, 1.05-2.19]; P = .03). The median chorea duration in patients receiving 1 or more months of corticosteroids was 1.2 months (95% CI, 1.2-2.0) vs 2.8 months (95% CI, 2.0-3.0) for patients receiving none (P = .004). Treatment factors associated with monophasic disease course were antibiotics (odds ratio [OR] for relapse, 0.28 [95% CI, 0.09-0.85]; P = .02), corticosteroids (OR, 0.32 [95% CI, 0.15-0.67]; P = .003), and sodium valproate (OR, 0.33 [95% CI, 0.15-0.71]; P = .004). Patients receiving at least 1 month of corticosteroids had significantly lower odds of relapsing course (OR, 0.10 [95% CI, 0.04-0.25]; P < .001). No treatment factor was associated with good functional outcome. Conclusions and Relevance In this meta-analysis of treatments and outcomes in patients with Sydenham chorea, immunotherapy, in particular corticosteroid treatment, was associated with faster resolution of chorea. Antibiotics, corticosteroids and sodium valproate were associated with a monophasic disease course. This synthesis of retrospective data should support the development of evidence-based treatment guidelines for patients with Sydenham chorea.
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Affiliation(s)
- Michael Eyre
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Terrence Thomas
- Department of Paediatrics, Neurology Service, KK Women’s and Children’s Hospital, Singapore
| | | | - Sonia Khamis
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Adrian Sie
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- NHS Lanarkshire, Bothwell, United Kingdom
| | - Tamsin Newlove-Delgado
- Children and Young People’s Mental Health (ChYMe) Research Collaboration, University of Exeter Medical School, Exeter, United Kingdom
| | - Michael Morton
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King’s College London, United Kingdom
| | - Russell C. Dale
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Westmead, Australia
| | - Ming Lim
- Faculty of Life Sciences and Medicine, King’s College London, United Kingdom
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute “Città della Speranza,” Padova, Italy
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Abstract
The spontaneous regression (SR) of cancer is defined as either partial or complete, and temporary or permanent, disappearance without appropriate treatment for the disease, and this phenomenon is rare in the case of small cell lung carcinoma (SCLC). We herein report an 83-year-old woman who presented with left-sided hemichorea associated with anti-SOX1 (SOX1-Ab) and -CV2/CRMP5 (CV2/CRMP5-Ab) antibodies with SR following a 7-year interval free of disease progression of SCLC. Hemichorea can present with the coexistence of anti-SOX1 and CV2/CRMP5-Ab with SR after a long interval free of SCLC. The immune response associated with these onco-neural antibodies may become independent of the original tumor trigger and remain active for many years.
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Affiliation(s)
- Koichi Shibata
- Department of Medicine, Tokyo Women's Medical University Medical Center East, Japan
| | - Yoshiko Nishimura
- Department of Medicine, Tokyo Women's Medical University Medical Center East, Japan
| | - Hiroshi Sakura
- Department of Medicine, Tokyo Women's Medical University Medical Center East, Japan
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3
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Abstract
BACKGROUND Our aim in this study was to evaluate the efficacy of magnetic resonance imaging (MRI) studies in the detection of brain regions effected by Sydenham chorea and to determine whether they provided data regarding the pathogenesis of Sydenham chorea. To this end, we assessed basal ganglia structures in Sydenham chorea patients and control group by quantitative MRI volumetric analysis. METHODS Patients with a recent onset of chorea and control subjects matched for age and gender were included in the study. Medical history, laboratory tests, and physical and neurologic examinations were reviewed. All MRIs were considered within normal limits. High-resolution T1-weighted 3D magnetization-prepared rapid acquisition of gradient echo scans were used for quantitative volumetric assessment of the brain via the "volBrain" method. RESULTS Twenty-four subjects with Sydenham chorea (16 girls and 8 boys, aged between 7 and 16 years) and 35 control subjects were evaluated. Mean age was 11.25 ± 2.89 years for Sydenham chorea patients and 10.58 ± 2.53 years for the controls. No significant difference was found relative to globus pallidus, caudate, and thalamic volumes between patients with Sydenham chorea and controls. The relative mean total, left, and right putamen volumes were significantly larger in patients with Sydenham chorea compared to controls (P = .003, P = .018, P = .001, respectively). CONCLUSION Selective neuroanatomic differences in putamen among other basal ganglia structures and significant increases in size are consistent with a hypothesis of a cross-reactive antibody-mediated inflammation of the putamen as being the pathophysiologic mechanism for this disorder.
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Affiliation(s)
- Zeynep Selen Karalok
- Department of Pediatric Neurology, 64032Akdeniz University School of Medicine, Antalya, Turkey
| | - Zeynep Öztürk
- Department of Pediatric Neurology, 146991Ankara Children's Hospital Hematology-Oncology Research and Training Hospital, Ankara, Turkey
| | - Altan Gunes
- Department of Pediatric Radiology, 146991Ankara Children's Hospital Hematology-Oncology Research and Training Hospital, Ankara, Turkey
| | - Esra Gurkas
- Department of Pediatric Neurology, 146991Ankara Children's Hospital Hematology-Oncology Research and Training Hospital, Ankara, Turkey
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Hanci F, Hizal M, Türay S, Kalaycioğlu O, Kabakuş N. Sydenham's Chorea; Clinical and Magnetic Resonance Imaging Findings, a Retrospective Observational Study in Children. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0039-1697041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AbstractThe purpose of this study was to evaluate the correlation between magnetic resonance imaging (MRI) findings and demographic and clinical characteristics, response to treatment times, and recurrence rates of Sydenham's chorea (SC), the most common of the acquired pediatric choreas. The clinical and radiological findings of 12 patients presenting to the pediatric neurology clinic in the previous 4 years and diagnosed with SC on the basis of the modified Jones criteria were investigated retrospectively from the hospital files. In addition, we measured the maximum prefrontal cortex and basal ganglia (globus pallidus, putamen, and caudate nucleus) thicknesses in the axial plane from patients' cerebral MRIs and compared these values with prefrontal cortex and basal ganglia thicknesses of a healthy control group measured using the same technique. Patient and control groups' cranial and basal ganglia MRIs were found to be normal. However, patients' globus pallidus thicknesses were significantly lower than those of the healthy control group. Additionally, the globus pallidus values of patients with recurrent SC and a prolonged healing time were lower than average. However, we determined no significant difference in terms of prefrontal motor cortex, caudate nucleus, or putamen thicknesses between the patient and control groups. Low globus pallidus thicknesses in patients with SC may indicate atrophy associated with globus pallidus involvement. Further experimental and prospective and long-term studies are needed for a better understanding of the factors affecting the pathophysiology, recurrence, and healing time of SC.
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Affiliation(s)
- Fatma Hanci
- Department of Pediatrics, Division of Child Neurology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Mustafa Hizal
- Department of Radiology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Sevim Türay
- Department of Pediatrics, Division of Child Neurology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Oya Kalaycioğlu
- Department of Biostatistics, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Nimet Kabakuş
- Department of Pediatrics, Division of Child Neurology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
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Ehrlich DJ, Walker RH. Functional neuroimaging and chorea: a systematic review. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2017. [PMID: 28649394 PMCID: PMC5479019 DOI: 10.1186/s40734-017-0056-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chorea is a hyperkinetic movement disorder consisting of involuntary irregular, flowing movements of the trunk, neck or face. Although Huntington’s disease is the most common cause of chorea in adults, chorea can also result from many other neurodegenerative, metabolic, and autoimmune conditions. While the pathophysiology of these different conditions is quite variable, recent advances in functional imaging have enabled the development of new methods for analysis of brain activity and neuronal dysfunction. In this paper we review the growing body of functional imaging data that has been performed in chorea syndromes and identify particular trends, which can be used to better understand the underlying network changes within the basal ganglia. While it can be challenging to identify whether changes are primary, secondary, or compensatory, identification of these trends can ultimately be useful in diagnostic testing and treatment in many of the conditions that cause chorea.
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Affiliation(s)
- Debra J Ehrlich
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 1st Floor, Box 1637, New York, NY 10029 USA
| | - Ruth H Walker
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 1st Floor, Box 1637, New York, NY 10029 USA.,Department of Neurology, James J Peters Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468 USA
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Giorgio SMDA, Caprio MG, Galante F, Russo G, Romano A, Vergara E, Alessio M, Cuocolo A. Clinical Value of Perfusion Abnormalities of Brain on Technetium-99m HMPAO Single-Photon Emission Computed Tomography in Children With Sydenham Chorea. J Child Neurol 2017; 32:316-321. [PMID: 27920268 DOI: 10.1177/0883073816681258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We evaluated whether perfusion brain abnormalities by single-photon emission computed tomography (SPECT) imaging improves diagnostic and prognostic assessment in Sydenham chorea. Twenty-three children with acute autoimmune chorea underwent technetium-99m hexamethylpropyleneamine oxime brain SPECT imaging. In 16 children, SPECT was repeated during the follow-up. A pattern of basal ganglia hyperperfusion was observed in 20 (87%) patients. In 4 of 10 patients with generalized chorea, perfusion was comparable in right and left striatum and right and left thalamus. In 13 patients with hemi-chorea and in 3 with generalized chorea, unilateral hyperperfusion was detected. Three patients with generalized chorea had normal perfusion. Tracer uptake of basal ganglia of the patients at the acute phase was higher than at the follow-up ( P < .001). SPECT seems a useful noninvasive tool in pediatric patients with Sydenham chorea to support the clinicians during the acute phase of disease and to monitor the course of autoimmune chorea.
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Affiliation(s)
| | - Maria Grazia Caprio
- 2 Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Flavia Galante
- 1 Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giustina Russo
- 3 Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alfonso Romano
- 3 Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Emilia Vergara
- 1 Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maria Alessio
- 3 Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alberto Cuocolo
- 1 Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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7
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Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham's chorea, PANDAS and beyond. Brain Res 2014; 1617:144-54. [PMID: 25301689 DOI: 10.1016/j.brainres.2014.09.071] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/29/2022]
Abstract
Infections, and the resulting immune response to these infections, have recently received increased recognition as pathogenic mechanisms for neuropsychiatric disorders. Sydenham's chorea (SC), a widely recognized post-streptococcal autoimmune disorder, represents a model for this proposed pathogenesis. In SC, a dysregulated immune response to a streptococcal infection is hypothesized to result in inflammation of neuronal networks, particularly the basal ganglia nuclei. The resulting dysfunction in the basal ganglia nuclei are hypothesized to lead to a constellation of adventitious movements and psychiatric symptoms, which investigations have shown are amenable to immunomodulatory therapies. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections) has been proposed as a variant of SC, and is hypothesized to share a pathogenic mechanism, despite a unique symptom profile of predominantly psychiatric symptoms. In this review, we present the clinical aspects of both disorders, the data for potential shared etiopathogenesis between them, and the evidence for the therapeutic use of immunomodulatory therapies for the symptoms of SC and PANDAS. This article is part of a Special Issue entitled SI: Neuroimmunology in Health And Disease.
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Affiliation(s)
- Kyle A Williams
- Pediatric Neuropsychiatry and Immunology Clinic, Department of Psychiatry, Massachusetts General Hospital, MA, United States; Department of Psychiatry, Harvard Medical School, MA 02114, United States.
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, National Institutes of Health, MA, United States
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8
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Lotan D, Cunningham M, Joel D. Antibiotic treatment attenuates behavioral and neurochemical changes induced by exposure of rats to group a streptococcal antigen. PLoS One 2014; 9:e101257. [PMID: 24979049 PMCID: PMC4076315 DOI: 10.1371/journal.pone.0101257] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 06/04/2014] [Indexed: 01/18/2023] Open
Abstract
Post-streptococcal A (GAS) sequelae including movement and neuropsychiatric disorders have been associated with improvement in response to antibiotic therapy. Besides eradication of infection, the underlying basis of attenuation of neuropsychiatric symptoms following antibiotic treatment is not known. The aim of the present study was to test the efficacy of antibiotic treatment in a rat model of GAS-related neuropsychiatric disorders. In the model, rats were not infected but were exposed to GAS-antigen or to adjuvants only (Control rats) and treated continuously with the antibiotic ampicillin in their drinking water from the first day of GAS-antigen exposure. Two additional groups of rats (GAS and Control) did not receive ampicillin in their drinking water. Behavior of the four groups was assessed in the forced swim, marble burying and food manipulation assays. We assessed levels of D1 and D2 dopamine receptors and tyrosine hydroxylase in the prefrontal cortex and striatum, and IgG deposition in the prefrontal cortex, striatum and thalamus. Ampicillin treatment prevented emergence of the motor and some of the behavioral alterations induced by GAS-antigen exposure, reduced IgG deposition in the thalamus of GAS-exposed rats, and tended to attenuate the increase in the level of TH and D1 and D2 receptors in their striatum, without concomitantly reducing the level of sera anti-GAS antibodies. Our results reinforce the link between exposure to GAS antigen, dysfunction of central dopaminergic pathways and motor and behavioral alterations. Our data further show that some of these deleterious effects can be attenuated by antibiotic treatment, and supports the latter's possible efficacy as a prophylactic treatment in GAS-related neuropsychiatric disorders.
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Affiliation(s)
- Dafna Lotan
- School of Psychological Sciences and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Madeleine Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Daphna Joel
- School of Psychological Sciences and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
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9
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Beato R, Siqueira CF, Marroni BJ, Boanova LG, de Lima CF, Maia DP, Nattan M, Cardoso F. Brain SPECT in Sydenham's chorea in remission. Mov Disord 2013; 29:256-8. [DOI: 10.1002/mds.25721] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 09/11/2013] [Accepted: 09/23/2013] [Indexed: 11/09/2022] Open
Affiliation(s)
- Rogério Beato
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Cristiano Ferrari Siqueira
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Belmonte J. Marroni
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Luciane Guerra Boanova
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Carla Flávia de Lima
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Débora Palma Maia
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Márcio Nattan
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Francisco Cardoso
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; The Federal University of Minas Gerais; Belo Horizonte MG Brazil
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10
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Abstract
Autoimmune diseases currently affect 5-7% of the world's population; in most diseases there are circulating autoantibodies. Brain-reactive antibodies are present in approximately 2-3% of the general population but do not usually contribute to brain pathology. These antibodies penetrate brain tissue only early in development or under pathologic conditions. This restriction on their pathogenicity and the lack of correlation between serum titers and brain pathology have, no doubt, contributed to a delayed appreciation of the contribution of autoantibodies in diseases of the central nervous system. Nonetheless, it is increasingly clear that antibodies can cause damage in the brain and likely initiate or aggravate multiple neurologic conditions; brain-reactive antibodies contribute to symptomatology in autoimmune disease, infectious disease, and malignancy.
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Affiliation(s)
- B Diamond
- Feinstein Institute for Medical Research, Manhasset, New York 11030, USA.
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11
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Abstract
Sydenham's chorea (SC) is the neurologic expression of acute rheumatic fever (ARF). Despite the declining incidence of ARF worldwide, it remains the most common cause of acute chorea in children. It is characterized by a combination of motor and nonmotor features. In addition to chorea, among the first are decreased muscle tone and tics. Nonmotor features include obsessions, compulsions, attention deficit, emotional lability, decreased verbal fluency, and executive dysfunction. Most patients present with nonneurologic features of ARF, such as carditis and arthritis. The pathogenesis is thought to involve streptococcus-induced antibodies which cross-react with antigens of the basal ganglia. The diagnosis is made on purely clinical grounds since there is no biological marker of the illness. The management is based on use of antichoreic agents, such as valproic acid and neuroleptics, and prophylaxis of new bouts of streptococcus infection with antibiotics. Although the motor features of SC come into spontaneous remission in the majority of patients, a significant proportion of individuals remain with persistent chorea.
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Affiliation(s)
- Francisco Cardoso
- Movement Disorders Clinic, Neurology Service, Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
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12
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Oosterveer DM, Overweg-Plandsoen WCT, Roos RAC. Sydenham's chorea: a practical overview of the current literature. Pediatr Neurol 2010; 43:1-6. [PMID: 20682195 DOI: 10.1016/j.pediatrneurol.2009.11.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 11/24/2009] [Accepted: 11/25/2009] [Indexed: 10/19/2022]
Abstract
Sydenham's chorea is characterized by uncoordinated movements, emotional instability, and hypotonia. It can occur up to several months after group A beta-hemolytic Streptococcus infection. A diagnosis of Sydenham's chorea in a patient with acute chorea involves an application of the Jones criteria and the exclusion of other causes of chorea. In patients with an atypical history or hemichorea, cranial magnetic resonance imaging is indicated to exclude other cerebral pathologies. A pathogenesis has not been elucidated, and therapy has not been investigated in placebo-controlled trials. Antibiotic treatment and a 2-week or 3-week schedule of antibiotic prophylaxis are recommended. If the chorea is severe, valproate or carbamazepine can be effective. In more severely affected patients, dopamine receptor blocking agents or corticosteroids can be used.
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Abstract
A seven year-old male presented to his pediatrician with choreiform movements and a recent history of sore throat. He was diagnosed with Sydenham's chorea based on clinical criteria and laboratory evidence. Worsening symptoms prompted a magnetic resonance imaging (MRI) of the brain which demonstrated evidence of Moyamoya disease. Sydenham's chorea is a common and well-documented complication of post-streptococcal infection, but has not been previously reported in association with Moyamoya disease. This case raises the quandary of causality of chorea in this patient and the need for neuroimaging in children with movement disorders.
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14
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Sato K, Nakagawa E, Saito Y, Komaki H, Sakuma H, Sugai K, Sasaki M, Kaido T, Nakama H, Otsuki T. Hyperkinetic movement disorder in a child treated by globus pallidus stimulation. Brain Dev 2009; 31:452-5. [PMID: 18801630 DOI: 10.1016/j.braindev.2008.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 07/26/2008] [Accepted: 08/02/2008] [Indexed: 10/21/2022]
Abstract
We report herein the case of a 9-year-old girl with life-threatening hyperkinetic involuntary movement of unknown etiology. Medical treatment was ineffective for her stereotypy and choreoathetotic/ballistic movements, but bilateral stimulation of the globus pallidus immediately alleviated these symptoms. Pallidal deep-brain stimulation may be considered the therapy of choice for children with intractable hyperkinetic movement disorders.
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Affiliation(s)
- Ken Sato
- Department of Child Neurology, National Center Hospital of Neurology and Psychiatry, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo, Japan
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15
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No evidence of perfusion abnormalities in the basal ganglia of a patient with generalized chorea-ballism and polycythaemia vera: analysis using subtraction SPECT co-registered to MRI. Neurol Sci 2008; 29:351-4. [PMID: 18941939 DOI: 10.1007/s10072-008-0994-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 07/18/2008] [Indexed: 10/21/2022]
Abstract
Polycythaemia vera is a well-known cause of symptomatic chorea, however, the pathophysiology of this correlation remains unclear. We report on a patient with generalized chorea-ballism associated with polycythaemia vera, and we present the findings of 99mTc-hexamethylpropylene amine oxime (HMPAO) SPECT done in both the choreic state and the non-choreic state. The SPECT during both the choreic and the non-choreic states did not reveal any definite perfusion changes in specific regions of the brain, as compared with 6 age-matched controls. In addition, the subtraction SPECT co-registered to MRI (SISCOM) analysis did not show any difference in cerebral blood flow during the choreic and non-choreic states. This result suggests that the basic mechanism of chorea associated with polycythaemia vera does not appear to be associated with a reduction in cerebral perfusion to a specific cerebral area, such as the basal ganglia or its thalamocortical connections.
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Demiroren K, Yavuz H, Cam L, Oran B, Karaaslan S, Demiroren S. Sydenham's chorea: a clinical follow-up of 65 patients. J Child Neurol 2007; 22:550-4. [PMID: 17690060 DOI: 10.1177/0883073807302614] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sydenham's chorea, the neurological manifestation of rheumatic fever, is the most common acquired chorea of childhood. In this retrospective study, the authors aim to present the clinical and laboratory findings of 65 Sydenham's chorea patients, followed up in a clinic over less than 7 years. The mean age at the onset of the symptoms was 11.7 +/- 2.6 years (range, 6-17 years). Of the patients, 63% were female and 37% were male (male/female: 1.7/1). Chorea was generalized in 78.5% of the patients, right hemichorea in 12.3%, and left hemichorea 9.2%. There was a history of rheumatic fever in 30.8% of the patients. Echocardiographic study showed cardiac valve involvement in 70.5% of 61 patients. Brain magnetic resonance imaging, which was performed on only 18 patients, was evaluated as normal in all. Electroencephalography was also performed on only 18 patients and showed abnormal waves in 50% of them. Pimozide was mostly the first choice of drug therapy. Nevertheless, drug therapy was not needed in 18.5% of the patients. The recovery period of the first attack of the chorea was 1 to 6 months in 51.7% of the patients. The recurrence rate was 37.9%. In conclusion, Sydenham's chorea is still an important health problem in Turkey with respect to its morbidity.
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Affiliation(s)
- Kaan Demiroren
- Department of Pediatrics, Cagri Tip Merkezi, Elazig, Turkey.
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17
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Abstract
Sydenham chorea (SC) is the neurological manifestation of rheumatic fever and is the most common acquired chorea in children. The disease presents as choreiform movements and behavioral changes after a streptoccocal throat infection. Although the incidence of SC has diminished because of aggressive antibiotic treatment, both isolated cases and epidemics persist, necessitating emergency physicians to be familiar with the disease. We describe the case of a 9-year-old girl with SC. A discussion of the pathophysiology, clinical presentation, and management of SC in the emergency department follows.
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Affiliation(s)
- Scott G Weiner
- Department of Emergency Medicine, Tufts-New England Medical Center, Boston, MA 02111, USA.
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Pavone P, Parano E, Rizzo R, Trifiletti RR. Autoimmune neuropsychiatric disorders associated with streptococcal infection: Sydenham chorea, PANDAS, and PANDAS variants. J Child Neurol 2006; 21:727-36. [PMID: 16970875 DOI: 10.1177/08830738060210091401] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Streptococcal infection in children is usually benign and self-limited. In a small percentage of children, prominent neurologic and/or psychiatric sequelae can occur. Sydenham chorea is the best defined and best recognized. PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) is a well-defined syndrome in which tics (motor and/or vocal) and/or obsessive-compulsive disorder consistently exacerbate in temporal correlation to a group A beta-hemolytic streptococcal infection. PANDAS constitutes a subset of children with tics, Tourette syndrome, and obsessive-compulsive disorder. In addition to strictly defined PANDAS, we and others have recognized several PANDAS variants, including adult-onset variant, a dystonic variant, a myoclonic variant, and a "chronic" PANDAS variant. The nosology and classification of these entities are rapidly evolving. The recognition that some pediatric neurobehavioral syndromes have infectious and/or immunologic triggers points to important new avenues of disease treatment. In this review, we summarize this complex and rapidly evolving area of clinical research.
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Affiliation(s)
- Piero Pavone
- Department of Pediatrics, Division of Clinical Pediatrics, University of Catania, Viale Andrea Doria 6, 95125 Catania, Italy.
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Engelen M, Tijssen MAJ. Paroxysmal non-kinesigenic dyskinesia in antiphospholipid syndrome. Mov Disord 2004; 20:111-3. [PMID: 15390045 DOI: 10.1002/mds.20262] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We report on a patient with a mixed movement disorder classifiable as a paroxysmal nonkinesigenic dyskinesia, occurring as the first manifestation of primary antiphospholipid syndrome (PAPS). Possible pathophysiology is discussed based on recent literature, and we stress that PAPS must be considered in movement disorders of a paroxysmal nature.
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Affiliation(s)
- Marc Engelen
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
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Demirören K, Tastekin G, Oran B. Diagnostic role of 99mTc hexamethyl-propyleneamine oxime brain single photon emission computed tomography in Sydenham's chorea. Pediatr Int 2004; 46:450-5. [PMID: 15310312 DOI: 10.1111/j.1442-200x.2004.01909.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The objective of this study was to determine whether technetium-99m hexamethyl-propyleneamine oxime (HMPAO) brain single photon emission computed tomography (SPECT) imaging is capable of detecting perfusional abnormalities in Sydenham's chorea (SC) patients and contributing to diagnosis of SC. METHODS In this study, 17 SC patients were evaluated. HMPAO SPECT was performed on all patients at the acute phase and six of them at the recovery phase. Magnetic resonance imaging (MRI) of the brain was performed to 13 patients. SPECT images of basal ganglia and thalamus were evaluated both visually and by measuring the radioactivity uptakes. Ten subjects constituted the control group. RESULTS HMPAO SPECT was visually evaluated as indicating hyperperfusion in the basal ganglia and thalamus in 16 patients, and evaluated as normal in one patient at the acute phase. The radioactivity uptakes of basal ganglia and thalamus of the patients at the acute phase were found statistically higher than those of the patients at the recovery phase, and also higher than those of the control group (P < 0.05). A significant difference between the radioactivity uptake of the patients at the recovery phase and those of the control group was not found (P > 0.05). Only one patient did not show any abnormality in both acute and recovery phases. MRI study did not show any abnormality in the basal ganglia and thalamus. CONCLUSION It is suggested that brain SPECT can contribute to the diagnosis of SC as an objective tool. Resolving of the hyperperfusion at the recovery phase provides further support for the diagnosis of SC.
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Affiliation(s)
- Kaan Demirören
- Department of Pediatrics, Meram Medical Faculty, Selçuk University, Konya, Turkey.
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Citak EC, Gücüyener K, Karabacak NI, Serdaroğlu A, Okuyaz C, Aydin K. Functional brain imaging in Sydenham's chorea and streptococcal tic disorders. J Child Neurol 2004; 19:387-90. [PMID: 15224712 DOI: 10.1177/088307380401900513] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Group A streptococcal infections cause a wide range of neuropsychiatric disorders, such as Sydenham's chorea, tics, obsessive-compulsive disorders, and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Structural (computed tomography and magnetic resonance imaging) and functional (positron emission tomography, single-photon emission computed tomography) imaging studies in patients with Sydenham's chorea have suggested reversible striatal abnormalities. The objective of this study was to investigate the cerebral perfusion patterns of the subcortical structures by using hexamethylpropylenamine oxime single-photon emission computed tomography (HMPAO-SPECT) in seven cases of Sydenham's chorea and two cases of streptococcal tic disorder. HMPAO-SPECT studies revealed a hyperperfusion pattern in two and a hypoperfusion pattern in five of the chorea patients and in two patients with tic disorder. The results are discussed in relation to the duration and severity of the symptoms and the response to therapy. Functional imaging findings can be variable in Sydenham's chorea, and hyperperfusion of the striatum and thalamus could be an indicator of the response to therapy and the severity of symptoms. However, the number of cases so far investigated by either SPECT or positron emission tomography is still too limited to draw any firm conclusions.
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Affiliation(s)
- Elvan Caglar Citak
- Department of Pediatric Neurology, Gazi University Medical Faculty, Ankara, Turkey
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van Toorn R, Weyers HH, Schoeman JF. Distinguishing PANDAS from Sydenham's chorea: case report and review of the literature. Eur J Paediatr Neurol 2004; 8:211-6. [PMID: 15261885 DOI: 10.1016/j.ejpn.2004.03.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children with Sydenham's chorea and PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal throat infections) share an array of neuropsychiatric symptoms and distinguishing one from the other, especially at onset can prove challenging. It is, however, important to distinguish between these two post-streptococcal disorders since their response to therapy differs. Children with Sydenham's chorea require long-term benzathine penicillin prophylaxis to reduce the risk of rheumatic heart disease. In contrast, the efficacy of penicillin prophylaxis in preventing tic or obsessive-compulsive symptom exacerbations in children with PANDAS remains doubtful. Immunomodulatory therapies such as plasma exchange and intravenous immunoglobulin have shown to reduce neuropsychiatric symptom severity in children with PANDAS. Tonsillectomy may also represent an effective treatment option in children severely affected by PANDAS. We present this case to demonstrate the pitfalls in differentiating between these two closely associated conditions in a developing country where the prevalence of rheumatic fever is high.
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Affiliation(s)
- Ronald van Toorn
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, P.O. Box 19063, Tygerberg 7505, Cape Town, South Africa.
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Abstract
Sydenham's chorea is an ancient disease that continues to afflict large numbers of children throughout the world. A major manifestation of rheumatic fever, Sydenham's chorea is commonly manifested by movement disorder and psychiatric problems, and also may be a marker for a life-threatening carditis. Because Sydenham's chorea is triggered by streptococcal pharyngitis, the most important component of its therapy is antibiotic prophylaxis against further streptococcal infections. Because the pathogenesis of Sydenham's chorea includes the production of anti-basal ganglia antibodies, therapies that modulate immune function or that restore neurotransmitter balance within the basal ganglia may be effective for Sydenham's chorea. Recent reports have suggested that Sydenham's chorea may be part of a spectrum of neuropsychiatric syndromes induced by streptococcal infection.
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Affiliation(s)
- Daniel J Bonthius
- Department of Pediatrics, College of Medicine, University of Iowa, Iowa City 52242, USA
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Hong YH, Ahn TB, Oh CW, Jeon BS. Hemichorea as an initial manifestation of moyamoya disease: reversible striatal hypoperfusion demonstrated on single photon emission computed tomography. Mov Disord 2002; 17:1380-3. [PMID: 12465089 DOI: 10.1002/mds.10245] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe a case with unilateral moyamoya disease that showed progressive hemichorea as an initial manifestation. Single photon emission computed tomography showed perfusion defect in the contralateral basal ganglia although magnetic resonance imaging was unremarkable. Hemichorea improved along with normalization of perfusion after bypass surgery, suggestive of striatal hypoperfusion as the cause of hemichorea.
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Affiliation(s)
- Yoon-Ho Hong
- Department of Neurology, Clinical Research Institute, Seoul National University Hospital, SNUMRC, College of Medicine, Seoul National University, Seoul, South Korea
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McMahon WM, Filloux FM, Ashworth JC, Jensen J. Movement disorders in children and adolescents. Neurol Clin 2002; 20:1101-24, vii-viii. [PMID: 12616683 DOI: 10.1016/s0733-8619(02)00015-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Tourette syndrome (TS), Sydenham chorea, and drug-induced dyskinesias are prototypical movement disorders affecting children. Underlying involvement of basal ganglia has been apparent for several decades, but new neuroimaging studies are adding detail to this mechanism. Genetic studies of TS and tardive dyskinesia may further reveal the underlying pathophysiology. Most provocative is the new conceptual model of poststreptococcal autoimmune neuropsychiatric disorder. Although unproven, substantial support for this model comes from immunologic, family, neuroimaging, and treatment studies.
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Affiliation(s)
- William M McMahon
- Departments of Psychiatry and Pediatrics, University of Utah, Salt Lake City, UT, USA.
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Barsottini OGP, Ferraz HB, Seviliano MM, Barbieri A. Brain SPECT imaging in Sydenham's chorea. Braz J Med Biol Res 2002; 35:431-6. [PMID: 11960191 DOI: 10.1590/s0100-879x2002000400004] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The objective of the present study was to determine whether brain single-photon emission computed tomography (SPECT) imaging is capable of detecting perfusional abnormalities. Ten Sydenham's chorea (SC) patients, eight females and two males, 8 to 25 years of age (mean 13.4), with a clinical diagnosis of SC were submitted to brain SPECT imaging. We used HMPAO labeled with technetium-99m at a dose of 740 MBq. Six examinations revealed hyperperfusion of the basal ganglia, while the remaining four were normal. The six patients with abnormal results were females and their data were not correlated with severity of symptoms. Patients with abnormal brain SPECT had a more recent onset of symptoms (mean of 49 days) compared to those with normal SPECT (mean of 85 days) but this difference did not reach statistical significance. Brain SPECT can be a helpful method to determine abnormalities of the basal ganglia in SC patients but further studies on a larger number of patients are needed in order to detect the phase of the disease during which the examination is more sensitive.
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Affiliation(s)
- O G P Barsottini
- Setor de Distúrbios do Movimento, Departamento de Neurologia, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Genel F, Arslanoglu S, Uran N, Saylan B. Sydenham's chorea: clinical findings and comparison of the efficacies of sodium valproate and carbamazepine regimens. Brain Dev 2002; 24:73-6. [PMID: 11891095 DOI: 10.1016/s0387-7604(01)00404-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sydenham's chorea is still the most frequently seen form of acquired chorea in childhood in developing world despite the use of antibiotics. It is a debilitating illness lasting for weeks or months and requires drug therapy. OBJECTIVE To evaluate and compare the efficacies of sodium valproate and carbamazepine in the treatment of the choreiform movements in Sydenham's chorea. DESIGN A prospective trial carried out with 24 children with Sydenham's chorea. PATIENTS Twenty-four patients were divided into two groups having similar demographic and clinical properties. One group (n = 17) was given carbamazepine (15 mg/kg per day) and the other (n = 7) was given sodium valproate (20-25 mg/kg per day). As soon as the symptoms were taken under control, doses of the drugs were tapered slowly. The duration of the drug use was recorded. The time of response to therapy was compared between the groups and the patients were monitored for the adverse effects. RESULTS There was no significant difference between the groups with respect to the time of clinical improvement and time of complete remission, duration of the therapy and the recurrence rates. Clinical improvement began by 8.0 +/- 4.0 days in sodium valproate and 7.4 +/- 8.2 days in carbamazepine group (P = 0.88). In the whole group no adverse effect was seen due to the drugs. CONCLUSION Carbamazepine and valproic acid are equally effective and safe drugs in the treatment of choreiform movements in Sydenham chorea.
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Affiliation(s)
- Ferah Genel
- Department of Pediatrics, Dr. Behçet Uz Children's Hospital, Cemal Gürsel cad. No: 182 daire:2, 35600 Karşiyaka/Izmir, Turkey.
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