1
|
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.
Collapse
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
| |
Collapse
|
2
|
Soller T, Roberts KV, Middleton BF, Ralph AP. Sydenham chorea in the top end of Australia's Northern Territory: A 20-year retrospective case series. J Paediatr Child Health 2023; 59:1210-1216. [PMID: 37589435 DOI: 10.1111/jpc.16481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
AIM Sydenham chorea is an immune-mediated neuropsychiatric condition, and a major criterion for diagnosis of acute rheumatic fever (ARF). Children in remote Northern Australia experience disproportionately high rates of ARF, yet studies looking at the epidemiology, clinical presentation and management of Sydenham chorea are limited in this population. METHODS We conducted a retrospective case series from January 2002 to April 2022 of all paediatric patients aged ≤18 years admitted to Royal Darwin Hospital with Sydenham chorea. Cases were identified using the hospital's clinical coding system (ICD10). Medical records were reviewed and data on demographics, clinical presentation, investigation results, treatment and outcome were extracted, deidentified and analysed. RESULTS One hundred ten presentations of Sydenham chorea occurred between 2002 and 2022, 109 (99%) of these were in First Nations children, with 85% residing in very remote locations. Most commonly, chorea presented as a generalised movement disorder affecting all four limbs (49%). Neuropsychiatric symptoms were reported in 33 (30%), and there was evidence of rheumatic heart disease on echocardiogram in 86 (78%) at presentation. All patients received benzathine penicillin, but there was significant variation in management of chorea, ranging from supportive management, to symptomatic management with anticonvulsants, to immunomodulatory medications including corticosteroids. CONCLUSION This case series highlights the significant burden of Sydenham chorea among First Nations children living in Northern Australia and demonstrates wide variation in treatment approaches. High-quality clinical trials are required to determine the best treatment for this disabling condition.
Collapse
Affiliation(s)
- Tasmyn Soller
- Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Kathryn V Roberts
- Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Bianca F Middleton
- Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Global Health Division, Menzies School of Health Research, John Mathews Building Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
| | - Anna P Ralph
- Global Health Division, Menzies School of Health Research, John Mathews Building Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
| |
Collapse
|
3
|
Wooding EL, Morton MJS, Lim M, Mitrofan O, Mushet N, Sie A, Knight B, Ford T, Newlove-Delgado T. Childhood/adolescent Sydenham's chorea in the UK and Ireland: a BPSU/CAPSS surveillance study. Arch Dis Child 2023; 108:736-741. [PMID: 37225279 PMCID: PMC10447407 DOI: 10.1136/archdischild-2023-325399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/30/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To conduct the first prospective surveillance study of Sydenham's chorea (SC) in the UK and Ireland, and to describe the current paediatric and child psychiatric service-related incidence, presentation and management of SC in children and young people aged 0-16 years. DESIGN Surveillance study of first presentations of SC reported by paediatricians via the British Paediatric Surveillance Unit (BPSU) and all presentations of SC reported by child and adolescent psychiatrists through the Child and Adolescent Psychiatry Surveillance System (CAPSS). RESULTS Over 24 months from November 2018, 72 reports were made via BPSU, of which 43 met the surveillance case definition of being eligible cases of suspected or confirmed SC. This translates to an estimated paediatric service-related incidence rate of new SC cases of 0.16 per 100 000 children aged 0-16 per year in the UK. No reports were made via CAPSS over the 18-month reporting period, although over 75% of BPSU cases presented with emotional and/or behavioural symptoms. Almost all cases were prescribed courses of antibiotics of varying duration, and around a quarter of cases (22%) received immunomodulatory treatment. CONCLUSIONS SC remains a rare condition in the UK and Ireland but has not disappeared. Our findings emphasise the impact that the condition can have on children's functioning and confirm that paediatricians and child psychiatrists should remain vigilant to its presenting features, which commonly include emotional and behavioural symptoms. There is a further need for development of consensus around identification, diagnosis and management across child health settings.
Collapse
Affiliation(s)
- Eva Louise Wooding
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- Department of Paediatrics, Royal Devon University Healthcare NHS Foundation Trust, Exeter, Devon, UK
| | | | - Ming Lim
- Children's Neurosciences Centre, Evelina Childrens Hospital, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Oana Mitrofan
- Faculty of Health and Life Sciences, University of Exeter, Exeter, Devon, UK
- Devon Partnership Trust, Exeter, UK
| | - Nadine Mushet
- CAMHS, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Adrian Sie
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
- NHS Lanarkshire, Bothwell, South Lanarkshire, UK
| | - Brodie Knight
- Royal Hospital for Sick Children Yorkhill, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Tamsin Newlove-Delgado
- Children and Young People's Mental Health (ChYMe) Research Collaboration, University of Exeter Medical School, Exeter, Devon, UK
| |
Collapse
|
4
|
Bovenzi R, Conti M, Schirinzi T. Pharmacotherapy for Sydenham's chorea: where are we and where do we need to be? Expert Opin Pharmacother 2023; 24:1317-1329. [PMID: 37204415 DOI: 10.1080/14656566.2023.2216380] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/17/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Sydenham's chorea (SC) is the most common cause of acquired chorea in children. The existing literature describes it as a benign, self-remitting condition. However, recent evidence discloses the persistence of long-course neuropsychiatric and cognitive complications in adulthood, which imposes to redefine the concept of 'benignity' of such condition. In addition, therapies are mostly empirical and non-evidence based. AREAS COVERED Here, we conducted an electronic exploration of the PubMed database and selected 165 relevant studies directly correlated to SC treatment. Critical data from selected articles were synthesized to provide an update on pharmacotherapy in SC, which basically consists of three pillars: antibiotic, symptomatic and immunomodulant treatments. Moreover, since SC mostly affects females with recurrences occurring in pregnancy (chorea gravidarum), we focused on the management in pregnancy. EXPERT OPINION SC is still a major burden in developing countries. The first therapeutic strategy should be the primary prevention of group A beta-hemolytic streptococcal (GABHS) infection. Secondary antibiotic prophylaxis should be performed in every SC patient as the World Health Organization (WHO) guidelines recommend. Symptomatic or immunomodulant treatments are administered according to clinical judgment. However, a greater effort to understand SC physiopathology is needed, together with larger trials, to outline appropriate therapeutic indications.
Collapse
Affiliation(s)
- Roberta Bovenzi
- Neurology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Matteo Conti
- Neurology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Tommaso Schirinzi
- Neurology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
5
|
Cappellari AM, Rogani G, Filocamo G, Petaccia A. Corticosteroid Treatment in Sydenham Chorea: A 27-Year Tertiary Referral Center Experience. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020262. [PMID: 36832391 PMCID: PMC9955750 DOI: 10.3390/children10020262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the effectiveness of corticosteroid therapy for children suffering from Sydenham chorea (SC). METHODS The design of the study was observational, retrospective and conducted at the single center of the Rheumatology Unit of Policlinic Hospital of Milan, Italy, from May 1995 to May 2022. All data about the patients were collected from medical records. RESULTS From a total of 59 patients enrolled in the study (44 females and 15 males; median age 9.3 years, range 7.4-10.6 years), 49 were eligible for primary outcome analysis (10 patients were excluded due to incomplete data). Overall, 75% of patients received steroid therapy, while the remaining cases were treated with symptomatic drugs, including neuroleptics and antiseizure drugs. We found that the duration of chorea was significantly shorter in patients treated with corticosteroids in comparison to those receiving symptomatic treatment (median time: 31 vs. 41 days, p = 0.023). Additionally, patients with arthritis at the onset of the disease had a longer duration of chorea than those without arthritis (median time 90.5 vs. 39 days, p = 0.02). We also found that chorea recurred in 12% of the patients and seemed to be linked to a younger age at onset (p = 0.01). CONCLUSIONS The study suggests that corticosteroid therapy can lead to a faster resolution of SC when compared to neuroleptics and antiseizure drugs treatment.
Collapse
Affiliation(s)
- Alberto Maria Cappellari
- Department of Neuroscience, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-025-503-2406
| | - Greta Rogani
- Department of Pediatrics, Università degli Studi di Milano, 20122 Milan, Italy
| | - Giovanni Filocamo
- Department of Pediatric Rheumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Antonella Petaccia
- Department of Pediatric Rheumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| |
Collapse
|
6
|
Orsini A, Foiadelli T, Sica A, Santangelo A, Carli N, Bonuccelli A, Consolini R, D’Elios S, Loddo N, Verrotti A, Di Cara G, Marra C, Califano M, Fetta A, Fabi M, Bergamoni S, Vignoli A, Battini R, Mosca M, Baldini C, Assanta N, Marchese P, Simonini G, Marrani E, Operto FF, Pastorino GMG, Savasta S, Santangelo G, Pedrinelli V, Massimetti G, Dell’Osso L, Peroni D, Cordelli DM, Corsi M, Carmassi C. Psychopathological Impact in Patients with History of Rheumatic Fever with or without Sydenham's Chorea: A Multicenter Prospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10586. [PMID: 36078300 PMCID: PMC9517806 DOI: 10.3390/ijerph191710586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 06/15/2023]
Abstract
Sydenham's chorea (SC) is a post-streptococcal autoimmune disorder of the central nervous system, and it is a major criterium for the diagnosis of acute rheumatic fever (ARF). SC typically improves in 12-15 weeks, but patients can be affected for years by persistence and recurrencies of both neurological and neuropsychiatric symptoms. We enrolled 48 patients with a previous diagnosis of ARF, with or without SC, in a national multicenter prospective study, to evaluate the presence of neuropsychiatric symptoms several years after SC's onset. Our population was divided in a SC group (n = 21), consisting of patients who had SC, and a nSC group (n = 27), consisting of patients who had ARF without SC. Both groups were evaluated by the administration of 8 different neuropsychiatric tests. The Work and Social Adjustment Scale (WSAS) showed significantly (p = 0.021) higher alterations in the SC group than in the nSC group. Furthermore, 60.4% (n = 29) of the overall population experienced neuropsychiatric symptoms other than choreic movements at diagnosis and this finding was significantly more common (p = 0.00) in SC patients (95.2%) than in nSC patients (33.3%). The other neuropsychiatric tests also produced significant results, indicating that SC can exert a strong psychopathological impact on patients even years after its onset.
Collapse
Affiliation(s)
- Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Attilio Sica
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Andrea Santangelo
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Niccolò Carli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Rita Consolini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Sofia D’Elios
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | - Nicolò Loddo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of Perugia, 06123 Perugia, Italy
| | - Giuseppe Di Cara
- Department of Pediatrics, University of Perugia, 06123 Perugia, Italy
| | - Chiara Marra
- Child Neurology Unit, University of Bologna, 40126 Bologna, Italy
| | - Maria Califano
- Child Neurology Unit, University of Bologna, 40126 Bologna, Italy
| | - Anna Fetta
- Child Neurology Unit, University of Bologna, 40126 Bologna, Italy
| | - Marianna Fabi
- Child Neurology Unit, University of Bologna, 40126 Bologna, Italy
| | - Stefania Bergamoni
- Childhood and Adolescence Neurology and Psychiatry Unit, ASST GOM Niguarda, 20121 Milan, Italy
| | - Aglaia Vignoli
- Childhood and Adolescence Neurology and Psychiatry Unit, ASST GOM Niguarda, 20121 Milan, Italy
- Health Sciences Department, Università degli Studi di Milano, 20121 Milan, Italy
| | - Roberta Battini
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
- Department of Developmental Neuroscience, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Fondazione Stella Maris, 56121 Pisa, Italy
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| | - Chiara Baldini
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| | - Nadia Assanta
- Heart Hospital, G. Monasterio Tuscan Foundation, 54100 Massa, Italy
| | - Pietro Marchese
- Heart Hospital, G. Monasterio Tuscan Foundation, 54100 Massa, Italy
| | - Gabriele Simonini
- Pediatric Rheumatology, Meyer Children Hospital, University of Florence, 50134 Florence, Italy
| | - Edoardo Marrani
- Pediatric Rheumatology, Meyer Children Hospital, University of Florence, 50134 Florence, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Grazia Maria Giovanna Pastorino
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | | | - Giuseppe Santangelo
- Child Neuropsychiatry Unit, ISMEP—P.O. Cristina—ARNAS Civico, Via dei Benedettini 1, 90100 Palermo, Italy
| | - Virginia Pedrinelli
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| | - Gabriele Massimetti
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| | - Liliana Dell’Osso
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| | - Diego Peroni
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56121 Pisa, Italy
| | | | - Martina Corsi
- Occupational Health Department, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Claudia Carmassi
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| |
Collapse
|
7
|
Orsini A, Foiadelli T, Magistrali M, Carli N, Bagnasco I, Dassi P, Verrotti A, Marcotulli D, Canavese C, Nicita F, Capuano A, Marra C, Fetta A, Nosadini M, Sartori S, Papa A, Viri M, Greco F, Pavone P, Simonini G, Matricardi S, Siquilini S, Marchese F, De Grandis E, Brunenghi BM, Malattia C, Bassanese F, Bergonzini P, Bonuccelli A, Consolini R, Marseglia GL, Peroni D, Striano P, Cordelli D, Savasta S. A nationwide study on Sydenham's chorea: Clinical features, treatment and prognostic factors. Eur J Paediatr Neurol 2022; 36:1-6. [PMID: 34768201 DOI: 10.1016/j.ejpn.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/19/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Sydenham's Chorea (SC) is a neuropsychiatric disorder and a major manifestation of acute rheumatic fever. The erroneous assumption that SC is a benign and self-limiting disease, has led to a lack of high-quality scientific evidence of the therapeutical and prognostic features of SC. STUDY DESIGN We retrospectively analyzed the medical records of patients <18-years old with SC in 17 Italian pediatric centers. Recorded data included clinical, instrumental and laboratory parameters. Prognostic risk factors including treatment regimens were assessed with univariate and multivariate sub-analysis. RESULTS We included 171 patients with SC. 66% had generalized chorea, and 34% hemichorea. 81% had carditis (subclinical in 65%). Additional neurological symptoms were reported in 60% of the patients, mainly dysarthria and dysgraphia. 51% had neuropsychiatric symptoms at onset, which persisted after 12 months in 10%. Among psychiatric manifestations, the most common was anxiety disorder/depression (77%). Neurological remission was reached by 93% of the patients at 6 months; 9% relapsed. Patients were treated as follows: 11% penicillin alone, 37% immunomodulatory therapy, 16% symptomatic drugs (i.e. anti-seizure medication, dopamine antagonists) and 37% both symptomatic and immunomodulatory treatment. Neurological outcome did not differ between groups. Patients receiving symptomatic drugs had a higher risk of relapse on multivariate analysis (p = 0.045). CONCLUSIONS Treatment of SC was largely heterogeneous. Based on our results, immunomodulatory therapy did not show higher efficacy at medium term, although it was associated to a slightly lower risk of relapse compared to symptomatic therapy. Longitudinal studies are needed to assess specific risk factors and best treatment options.
Collapse
Affiliation(s)
- Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Mariasole Magistrali
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Niccolò Carli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Irene Bagnasco
- U.O Neuropsichiatria Infantile, Ospedale Martini-Torino, Turin, Italy
| | - Patrizia Dassi
- U.O Neuropsichiatria Infantile, Ospedale Martini-Torino, Turin, Italy
| | | | - Daniele Marcotulli
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Carlotta Canavese
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Francesco Nicita
- Unit of Muscular and Neurodegenerative Diseases, Department of Neurosciences, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandro Capuano
- Movement Disorders Clinic- Neurology Unit- Department of Neurosciences, Bambino Gesù Children's Hospital, Rome, Italy
| | - Chiara Marra
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - Anna Fetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - 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
| | - Stefano Sartori
- 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
| | - Amanda Papa
- Infantile Neuropsychiatry Department Maggiore della Carità University Hospital, Novara, Italy
| | - Maurizio Viri
- Infantile Neuropsychiatry Department Maggiore della Carità University Hospital, Novara, Italy
| | - Filippo Greco
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Piero Pavone
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Gabriele Simonini
- Pediatric Rheumatology, Anna Meyer Children University Hospital, Florence, Italy
| | - Sara Matricardi
- Department of Child Neuropsychiatry, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Ancona, Italy
| | - Sabrina Siquilini
- Department of Child Neuropsychiatry, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Ancona, Italy
| | - Francesca Marchese
- Pediatric Neurology Unit, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Elisa De Grandis
- Child Neuropsychiatry Unit, Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Children's Sciences, University of Genoa, Genoa, Italy
| | - Bernadette Marrè Brunenghi
- Child Neuropsychiatry Unit, Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Children's Sciences, University of Genoa, Genoa, Italy
| | - Clara Malattia
- Child Neuropsychiatry Unit, Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Children's Sciences, University of Genoa, Genoa, Italy
| | - Francesco Bassanese
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Patrizia Bergonzini
- Pediatric Department, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Pediatric Rheumatology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Diego Peroni
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Pasquale Striano
- Pediatric Neurology Unit, Istituto Giannina Gaslini, University of Genoa, Genoa, Italy; Child Neuropsychiatry Unit, Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Children's Sciences, University of Genoa, Genoa, Italy
| | - Duccio Cordelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - Salvatore Savasta
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| |
Collapse
|
8
|
Teixeira AL, Vasconcelos LP, Nunes MDCP, Singer H. Sydenham's chorea: from pathophysiology to therapeutics. Expert Rev Neurother 2021; 21:913-922. [PMID: 34353207 DOI: 10.1080/14737175.2021.1965883] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sydenham's chorea is an autoimmune chorea emerging after a group A beta-hemolytic streptococcal (GABHS) infection, i.e. a rheumatic chorea with or without the presence of carditis or arthritis. The disorder, defined by the presence of chorea, is also associated with cognitive and behavioral symptoms, including emotional lability, anxiety, depressive and obsessive-compulsive symptoms. The authors review the pathophysiology, clinical characteristics, and available evidence on therapeutic strategies, the latter including the secondary prevention of GABHS infections, reduction of chorea, and immune modulation. Sydenham's chorea has been regarded as a model for pediatric autoimmune neuropsychiatric disorders, however, the field is marked by conflicting results and controversies. Regarding therapeutics, there are limited high-quality interventional studies and the selection of treatment strategy often relies on the clinician's experience. A serial treatment algorithm is presented based upon the severity of clinical presentation and response to symptomatic pharmacotherapy.
Collapse
Affiliation(s)
- Antonio L Teixeira
- Infectious Diseases and Tropical Medicine Graduation Program, School of Medicine, Universidade Federal De Minas Gerais, Belo Horizonte, Brazil.,Institute of Education and Research, Santa Casa Bh, Belo Horizonte, Brazil.,Neuropsychiatry Program, Ut Health Science Center at Houston, USA
| | - Luiz P Vasconcelos
- Infectious Diseases and Tropical Medicine Graduation Program, School of Medicine, Universidade Federal De Minas Gerais, Belo Horizonte, Brazil
| | - Maria do Carmo Pereira Nunes
- Infectious Diseases and Tropical Medicine Graduation Program, School of Medicine, Universidade Federal De Minas Gerais, Belo Horizonte, Brazil
| | - Harvey Singer
- Department of Neurology, Johns Hopkins Medicine and Kennedy Krieger Institute, Baltimore, MD, USA
| |
Collapse
|
9
|
Abstract
Movement disorders presenting in childhood include tics, dystonia, chorea, tremor, stereotypy, myoclonus, and parkinsonism, each of which can be part of various clinical syndromes with distinct etiologies. Some of these conditions are benign and require only reassurance; others are bothersome and require treatment, or may be clues that herald underlying pathology. Answers lie in the inherent characteristics of the movements themselves, together with the clinical context provided in the history obtained by the examiner. The aim of this review is to present an overview of the categories of involuntary movements, along with examples of common acquired and genetic causes, and an approach to history-taking, examination, and treatment.
Collapse
Affiliation(s)
- Joanna Blackburn
- Division of Child Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Mered Parnes
- Pediatric Movement Disorders Clinic, Section of Pediatric Neurology and Developmental Neuroscience, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, United States.
| |
Collapse
|
10
|
Marino A, Cimaz R, Pelagatti MA, Tattesi G, Biondi A, Menni L, Sala M, Calzi P, Morandi F, Cortinovis F, Cogliardi A, Addis C, Bellù R, Andreotti M, Varisco T. Acute Rheumatic Fever: Where Do We Stand? An Epidemiological Study in Northern Italy. Front Med (Lausanne) 2021; 8:621668. [PMID: 33718402 PMCID: PMC7943448 DOI: 10.3389/fmed.2021.621668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/14/2021] [Indexed: 01/26/2023] Open
Abstract
Acute rheumatic fever (ARF) is a non-septic complication of group A β-hemolytic streptococcal (GAS) throat infection. Since 1944, ARF diagnosis relies on the Jones criteria, which were periodically revised. The 2015 revision of Jones criteria underlines the importance of knowing the epidemiological status of its own region with updated data. This study aims to describe ARF features in a retrospective cohort retrieved over a 10-year timespan (2009–2018) and to report the annual incidence of ARF among children in the Province of Monza-Brianza, Lombardy, Italy during the same period. This is a multicentric cross-sectional/retrospective study; 70 patients (39 boys) were diagnosed with ARF. The median age at diagnosis was 8.5 years (range, 4–14.2 years). Overall, carditis represented the most reported major Jones criteria followed by arthritis and chorea (40, 27, and 20 cases, respectively). In order to calculate the annual incidence of ARF, only children resident in the Province of Monza-Brianza were included in this part of the analysis. Therefore, 47 patients aged between 5 and 14 years were identified. The median incidence during the study time was 5.7/100,000 (range, 2.8–8.3/100,000). In the Province of Monza-Brianza, we found an incidence rate of ARF among children aged 5–14 years constantly above the threshold of low-risk area as defined in the 2015 revision of Jones criteria. Therefore, the diagnosis of ARF should be based on the moderate–high-risk set of Jones criteria. However, given the burden of secondary prophylaxis, expert opinion is advisable when the diagnosis of ARF is uncertain.
Collapse
Affiliation(s)
- Achille Marino
- Department of Pediatrics, Desio Hospital, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Rolando Cimaz
- Azienda Socio Sanitaria Territoriale G.Pini-Centro Traumatologico Ortopedico, Milan, Italy.,Department of Clinical Sciences and Community Health, and Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
| | - Maria Antonietta Pelagatti
- Department of Pediatrics, Milano-Bicocca University Monza e Brianza per il Bambino e la sua Mamma Foundation, Monza, Italy
| | - Giulia Tattesi
- Department of Pediatrics, Milano-Bicocca University Monza e Brianza per il Bambino e la sua Mamma Foundation, Monza, Italy
| | - Andrea Biondi
- Department of Pediatrics, Milano-Bicocca University Monza e Brianza per il Bambino e la sua Mamma Foundation, Monza, Italy
| | - Laura Menni
- Department of Pediatrics, Vimercate Hospital, Vimercate, Italy
| | - Marco Sala
- Department of Pediatrics, Vimercate Hospital, Vimercate, Italy
| | - Patrizia Calzi
- Department of Pediatrics, Carate Hospital, Carate Brianza, Italy
| | - Francesco Morandi
- Department of Pediatrics, San Leopoldo Mandic Hospital, ASST Lecco, Lecco, Italy
| | - Francesca Cortinovis
- Department of Pediatrics, San Leopoldo Mandic Hospital, ASST Lecco, Lecco, Italy
| | - Anna Cogliardi
- Department of Pediatrics, Lecco Hospital, ASST Lecco, Lecco, Italy
| | - Claudia Addis
- Department of Pediatrics, Lecco Hospital, ASST Lecco, Lecco, Italy
| | - Roberto Bellù
- Department of Pediatrics, Lecco Hospital, ASST Lecco, Lecco, Italy
| | - Massimo Andreotti
- Department of Pediatrics, Desio Hospital, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Tiziana Varisco
- Department of Pediatrics, Desio Hospital, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| |
Collapse
|