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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.
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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
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Depietri G, Carli N, Sica A, Oliviero D, Costagliola G, Striano P, Bonuccelli A, Frisone F, Peroni D, Consolini R, Foiadelli T, Orsini A. Therapeutic aspects of Sydenham's Chorea: an update. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021414. [PMID: 35441610 PMCID: PMC9179053 DOI: 10.23750/abm.v92is4.12663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 12/15/2022]
Abstract
Sydenham’s Chorea (SC) is a hyperkinetic movement disorder associated with neuropsychiatric manifestations. It is believed to be caused by the autoimmune response following a group A beta-hemolytic streptococcal (GABHS) pharyngitis, and it is one of the major diagnostic criteria for Acute Rheumatic Fever (ARF) diagnosis. Despite having been known and studied for centuries, there are still no standardized therapies or official guidelines for SC treatment, so that it is necessarily left to physicians’ clinical experience. Antibiotic treatment, symptomatic therapies, and immunomodulatory treatment are the three pillars upon which SC patients’ management is currently based, but they still lack a solid scientific basis. The aim of this writing is precisely to review the state of the art of SC’s treatment, with an overview of the advances made in the last 5 years. However, since the therapeutic uncertainties are a mere reflection of the severe gap of knowledge that concerns SC’s pathogenesis and manifestations, the importance of high-quality research studies based on homogenized methodologies, instruments, and measured outcomes will also be stressed. (www.actabiomedica.it)
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Affiliation(s)
- Greta Depietri
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Niccolo Carli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Attilio Sica
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Domenico Oliviero
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Giorgio Costagliola
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Pasquale Striano
- Pediatric Neurology Unit, Dinogmi, Giannina Gaslini's. Istitute, University of Genoa, Italy.
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Flavia Frisone
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Diego Peroni
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Rita Consolini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia.
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
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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.
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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
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Valproate for schizophrenia: ambrosia? CNS Spectr 2021; 26:314-315. [PMID: 32241333 DOI: 10.1017/s1092852920001285] [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: 11/05/2022]
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Abstract
PURPOSE OF REVIEW This article provides an overview of the approach to chorea in clinical practice, beginning with a discussion of the phenomenologic features of chorea and how to differentiate it from other movement disorders. The diagnostic approach, clinical features of important acquired and genetic choreas, and therapeutic principles are also discussed. Practical clinical points and caveats are included. RECENT FINDINGS C9orf72 disease is the most common Huntington disease phenocopy, according to studies in the European population. Anti-IgLON5 disease can present with chorea. The role of immunotherapies in Sydenham chorea has increased, and further clinical studies may be useful. Benign hereditary chorea is a syndrome or phenotype due to mutations in several genes, including NKX2-1, ADCY5, GNAO1, and PDE10A. New-generation presynaptic dopamine-depleting agents provide more options for symptomatic treatment of chorea with fewer adverse effects. Deep brain stimulation has been performed in several choreic disorders, but features other than chorea and the neurodegenerative nature should be taken into consideration. Studies on genetic interventions for Huntington disease are ongoing. SUMMARY Clinical features remain crucial in guiding the differential diagnosis and appropriate investigations in chorea. Given the complexity of most choreic disorders, treating only the chorea is not sufficient. A comprehensive and multidisciplinary approach is required.
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Vasconcelos LPB, Vasconcelos MC, Nunes MDCP, Teixeira AL. Sydenham’s chorea: an update on pathophysiology, clinical features and management. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1684259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Luiz Paulo Bastos Vasconcelos
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marcelle Cristina Vasconcelos
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maria Do Carmo Pereira Nunes
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Antonio Lucio Teixeira
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Neuropsychiatry Program, UT Health Science Center, Houston, TX, USA
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Abstract
Over the last decade, there have been significant advances in the identification, characterization, and treatment of autoimmune neurologic disorders in children. Many of these diseases include a typical movement disorder that can be a powerful aid to diagnosis. Frequently, movement disorders in autoimmune conditions are the sole or among a few presenting symptoms, allowing for earlier diagnosis of an underlying malignancy or systemic autoimmune disease. Given that early detection and treatment with immunotherapy may confer improved outcomes, recognizing these patterns of abnormal movements is essential for child neurologists. The purpose of this review is to summarize the clinical characteristics, diagnosis, and treatment of movement disorders that occur in pediatric autoimmune disorders.
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8
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Fusco C, Spagnoli C. Corticosteroid treatment in Sydenham's chorea. Eur J Paediatr Neurol 2018; 22:327-331. [PMID: 29287833 DOI: 10.1016/j.ejpn.2017.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/25/2017] [Accepted: 11/28/2017] [Indexed: 11/25/2022]
Abstract
Sydenham's chorea (SC) is an immune-mediated hyperkinetic movement disorder, developing after group A Beta-hemolytic streptococcal (GABHS) infection. Aside from conventional symptomatic treatment (carbamazepine, valproate, neuroleptics), the use of steroids has also been advocated, mainly in severe, drug-resistant cases or if clinically disabling side effects develop with first line therapies. Based on the description of 5 cases followed in the Child Neurology Unit of Santa Maria Nuova Hospital in Reggio Emilia and on the available medical literature on this topic, we propose considering the use of corticosteroids therapy in children with SC, with the administration of IV methyl-prednisolone followed by oral deflazacort in severe cases and of oral deflazacort alone in mild and moderate degrees of involvement. In our experience this therapy is effective both in the short and long-term period, in different clinical presentations (chorea paralytica, distal chorea, hemichorea, "classic" chorea, association with mood disorder or dyspraxia) and very well tolerated (no significant side effects were recorded).
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Affiliation(s)
- C Fusco
- Department of Pediatrics, Child Neurology and Psychiatry Unit, Arcispedale Santa Maria Nuova, IRCCS, Viale Risorgimento 80, 42123 Reggio Emilia, Italy.
| | - C Spagnoli
- Department of Pediatrics, Child Neurology and Psychiatry Unit, Arcispedale Santa Maria Nuova, IRCCS, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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Walker KG, de Vries PJ, Stein DJ, Wilmshurst JM. Sydenham Chorea and PANDAS in South Africa: Review of Evidence and Recommendations for Management in Resource-Poor Countries. J Child Neurol 2015; 30:850-9. [PMID: 25227516 DOI: 10.1177/0883073814544704] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/28/2014] [Indexed: 11/15/2022]
Abstract
In South Africa, and worldwide, rheumatic fever represents a public health problem. Improved diagnosis and management of Sydenham chorea, a major manifestation of acute rheumatic fever is key to prevention of rheumatic heart disease. This article reviews Sydenham chorea from its original description to current opinions. Recommendations are founded on expert opinion as class 1 data is lacking. This South African perspective is relevant to resource-poor settings globally insofar as it provides diagnosis and management recommendations for primary- and secondary-level healthcare professionals who care for patients in such environments. Four basic tenets of care are recommended, namely, elimination of the streptococcal infection, symptomatic treatment, immunological treatment, and nonpharmacologic interventions. A user-friendly outcome measurement tool, viable for use in low-resource settings is presented. Introduction of this tool may lead to increased awareness of the neuropsychiatric manifestations of poststreptococcal movement disorders in Africa, where reports are limited.
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Affiliation(s)
- Kathleen G Walker
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa Rheumatic Fever Clinic, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Petrus J de Vries
- Division of Child & Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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Miranda M, Walker RH, Saez D, Renner V. Severe Sydenham's chorea (chorea paralytica) successfully treated with plasmapheresis. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2015; 2:2. [PMID: 26788338 PMCID: PMC4711077 DOI: 10.1186/s40734-014-0012-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 10/29/2014] [Indexed: 11/16/2022]
Abstract
Sydenham’s chorea is often regarded as a relatively benign and self-limiting condition. Treatment is typically symptomatic, although occasionally immunomodulatory therapies are required in severe forms. Here we report a girl who was affected with the severe variant, chorea paralytica, who responded dramatically and rapidly to plasmapheresis, having failed other therapies.
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Affiliation(s)
- Marcelo Miranda
- Department of Neurology, Clinica Las Condes, Santiago, Chile
| | - Ruth H Walker
- Department of Neurology (127), James J. Peters Veterans Affairs Medical Center, 130 W. Kingsbridge Road, Bronx, NY 10468 USA ; Mount Sinai School of Medicine, New York, USA
| | - David Saez
- Department of Neurology, Hospital Barros Luco, Santiago, Chile
| | - Victoria Renner
- Department of Neurology, Clinica Las Condes, Santiago, Chile
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Brogna C, Mariotti P, Manna R. Conventional and intravenous immunoglobulin therapy in paediatric antiphospholipid antibodies-related chorea. Lupus 2014; 23:1449-51. [PMID: 25237169 DOI: 10.1177/0961203314551084] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- C Brogna
- Department of Pediatric Neurology, Catholic University of the Sacred Heart, Rome, Italy
| | - P Mariotti
- Department of Pediatric Neurology, Catholic University of the Sacred Heart, Rome, Italy
| | - R Manna
- Department of Internal Medicine, Periodic Fevers Research Centre, Clinical Autoimmunity Unit, Catholic University of the Sacred Heart, Rome, Italy
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El Otmani H, Moutaouakil F, Fadel H, Slassi I. Chorea paralytica: a videotape case with rapid recovery and good long-term outcome. Acta Neurol Belg 2013; 113:515-7. [PMID: 23797350 DOI: 10.1007/s13760-013-0214-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 05/30/2013] [Indexed: 11/30/2022]
Abstract
Chorea paralytica (or chorea mollis) is a very rare variant of Sydenham's chorea, characterized by a profound hypotonia, resulting in severe disability. Given the rarity of this condition, data on its prognosis are lacking. Most reports suggest that the delay from onset to recover total autonomy is long, usually several weeks to months which strongly affects the quality of life of these children. We report a videotape case of a 14-year-old girl, who became rapidly bedridden because of severe generalized chorea paralytica. Her clinical picture was totally improved 7 days only after initiation of an "aggressive" treatment, combining steroid pulse, haloperidol and long-term penicillin G, with no relapse after 4-year follow-up. We believe that the best care of this rare and severe form of Sydenham's chorea, should combine pathophysiological treatment with corticosteroids, preferably by pulse-therapy, symptomatic antichoreic treatment by neuroleptics, associated with a long-term antibiotic use to reduce recurrence risk.
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Fusco C, Ucchino V, Frattini D, Pisani F, Della Giustina E. Acute and chronic corticosteroid treatment of ten patients with paralytic form of Sydenham's chorea. Eur J Paediatr Neurol 2012; 16:373-8. [PMID: 22197452 DOI: 10.1016/j.ejpn.2011.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 11/26/2011] [Accepted: 12/03/2011] [Indexed: 10/14/2022]
Abstract
AIMS To determine efficacy and safety of corticosteroid treatment in patients with severe Sydenham's chorea paralytic form. METHODS This is a 4 years observational study on ten patient with severe paralytic form of Sydenham's chorea unresponsive to neuroleptics and antiepileptics agents, treated with intravenous methylprednisolone followed by oral deflazacort therapy. Chorea paralytica patients were bedridden, unable to take independent steps, showed severe generalized hypotonia and were hospitalized for 3-4 weeks. Additional clinical evaluations were undertaken at 1, 3 and 6 months and 1, 2 and 4 years from onset of chorea. Severity chorea at the onset and during follow up was rated according to Universidade Federal de Minas Gerais (UFMG) Sydenham's Chorea Rating Scale (USCRS). In all children video-recording was performing at onset and during clinical follow-up. RESULTS We reported a significant improvement in swallowing and chewing with partial recovery of language 2-3 days after starting intravenous methylprednisolone treatment and complete disappearance of movement disorders after 3-4 weeks of treatment. All our patients were followed for 4 years from onset and none experienced relapse of chorea, other movement disorders or psychiatric disturbances. The treatment with deflazacort was well-tolerated in all children with no significant side effects reported. CONCLUSION Our data showed that high dose of methylprednisolone intravenously followed by deflazacort therapy may be effective and well-tolerated in children with severe paralytic form of Sydenham's chorea.
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Affiliation(s)
- Carlo Fusco
- Pediatric Neurology Unit, Arcispedale Santa Maria Nuova, V.le Risorgimento 80, 42123 Reggio Emilia, Italy.
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15
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Baizabal-Carvallo JF, Jankovic J. Movement disorders in autoimmune diseases. Mov Disord 2012; 27:935-46. [PMID: 22555904 DOI: 10.1002/mds.25011] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 03/09/2012] [Accepted: 03/26/2012] [Indexed: 12/13/2022] Open
Abstract
Movement disorders have been known to be associated with a variety of autoimmune diseases, including Sydenham's chorea, pediatric autoimmune neuropsychiatric disorders associated with streptococcus, systemic lupus erythematosus, antiphospholipid syndrome, gluten sensitivity, paraneoplastic and autoimmune encephalopathies. Tremors, dystonia, chorea, ballism, myoclonus, parkinsonism, and ataxia may be the initial and even the only presentation of these autoimmune diseases. Although antibodies directed against various cellular components of the central nervous system have been implicated, the pathogenic mechanisms of these autoimmune movement disorders have not yet been fully elucidated. Clinical recognition of these autoimmune movement disorders is critically important as many improve with immunotherapy or dietary modifications, particularly when diagnosed early. We discuss here the clinical features, pathogenic mechanisms, and treatments of movement disorders associated with autoimmune diseases, based on our own experience and on a systematic review of the literature.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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Balottin U, Calcaterra E, Zambonin F, Veggiotti P, Luoni C, Termine C. Chorea mollis: long-term follow-up of an infantile case. Neurol Sci 2011; 33:643-5. [DOI: 10.1007/s10072-011-0806-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 09/16/2011] [Indexed: 11/30/2022]
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Wills S, Rossi CC, Bennett J, Martinez-Cerdeño V, Ashwood P, Amaral DG, Van de Water J. Further characterization of autoantibodies to GABAergic neurons in the central nervous system produced by a subset of children with autism. Mol Autism 2011; 2:5. [PMID: 21521495 PMCID: PMC3108923 DOI: 10.1186/2040-2392-2-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 04/26/2011] [Indexed: 11/10/2022] Open
Abstract
Background Autism is a neurodevelopmental disorder characterized by impairments in social interaction and deficits in verbal and nonverbal communication, together with the presence of repetitive behaviors or a limited repertoire of activities and interests. The causes of autism are currently unclear. In a previous study, we determined that 21% of children with autism have plasma autoantibodies that are immunoreactive with a population of neurons in the cerebellum that appear to be Golgi cells, which are GABAergic interneurons. Methods We have extended this analysis by examining plasma immunoreactivity in the remainder of the brain. To determine cell specificity, double-labeling studies that included one of the calcium-binding proteins that are commonly colocalized in GABAergic neurons (calbindin, parvalbumin or calretinin) were also carried out to determine which GABAergic neurons are immunoreactive. Coronal sections through the rostrocaudal extent of the macaque monkey brain were reacted with plasma from each of seven individuals with autism who had previously demonstrated positive Golgi cell staining, as well as six negative controls. In addition, brain sections from adult male mice were similarly examined. Results In each case, specific staining was observed for neurons that had the morphological appearance of interneurons. By double-labeling sections with plasma and with antibodies directed against γ-aminobutyric acid (GABA), we determined that all autoantibody-positive neurons were GABAergic. However, not all GABAergic neurons were autoantibody-positive. Calbindin was colabeled in several of the autoantibody-labeled cells, while parvalbumin colabeling was less frequently observed. Autoantibody-positive cells rarely expressed calretinin. Sections from the mouse brain processed similarly to the primate sections also demonstrated immunoreactivity to interneurons distributed throughout the neocortex and many subcortical regions. Some cell populations stained in the primate (such as the Golgi neurons in the cerebellum) were not as robustly immunoreactive in the mouse brain. Conclusions These results suggest that the earlier report of autoantibody immunoreactivity to specific cells in the cerebellum extend to other regions of the brain. Further, these findings confirm the autoantibody-targeted cells to be a subpopulation of GABAergic interneurons. The potential impact of these autoantibodies on GABAergic disruption with respect to the etiology of autism is discussed herein.
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Affiliation(s)
- Sharifia Wills
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, 451 Health Sciences Drive, Suite 6510 GBSF, Davis, CA 95616, USA.,NIEHS Center for Children's Environmental Health, University of California, Davis, Davis, CA 95616, USA
| | - Christy C Rossi
- Department of Psychiatry and Behavioral Sciences, Center for Neuroscience, California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA.,The M.I.N.D. Institute, University of California Davis Medical Center, Sacramento, CA 95817 USA
| | - Jeffrey Bennett
- Department of Psychiatry and Behavioral Sciences, Center for Neuroscience, California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA.,The M.I.N.D. Institute, University of California Davis Medical Center, Sacramento, CA 95817 USA
| | - Veronica Martinez-Cerdeño
- Department of Psychiatry and Behavioral Sciences, Center for Neuroscience, California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA.,The M.I.N.D. Institute, University of California Davis Medical Center, Sacramento, CA 95817 USA
| | - Paul Ashwood
- Department of Medical Microbiology and Immunology, University of California at Davis, Davis, CA 95616, USA.,The M.I.N.D. Institute, University of California Davis Medical Center, Sacramento, CA 95817 USA.,NIEHS Center for Children's Environmental Health, University of California, Davis, Davis, CA 95616, USA
| | - David G Amaral
- Department of Psychiatry and Behavioral Sciences, Center for Neuroscience, California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA.,The M.I.N.D. Institute, University of California Davis Medical Center, Sacramento, CA 95817 USA
| | - Judy Van de Water
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, 451 Health Sciences Drive, Suite 6510 GBSF, Davis, CA 95616, USA.,The M.I.N.D. Institute, University of California Davis Medical Center, Sacramento, CA 95817 USA.,NIEHS Center for Children's Environmental Health, University of California, Davis, Davis, CA 95616, USA
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Walker KG. An update on the treatment of Sydenham's chorea: the evidence for established and evolving interventions. Ther Adv Neurol Disord 2010; 3:301-9. [PMID: 21179620 PMCID: PMC3002660 DOI: 10.1177/1756285610382063] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Over 320 years after Thomas Sydenham described the condition labelled Sydenham's chorea, it remains poorly understood. The disorder is an antineuronal antibody-mediated neuropsychiatric disorder caused by a poststreptococcal, autoimmune condition affecting control of movement, mood, behaviour and potentially the heart. The treatment remains empirical, and is less than optimal. There are few large clinically controlled trials. Recommendations for optimal management remain inconsistent and are hampered by the side effects from pharmacotherapy. Care for patients should be targeted at primary treatment (penicillin and bed rest), secondary palliation (symptomatic medication) and supportive (social) care. Small studies have demonstrated trends to support the use of immunoglobulins and steroids as therapeutic interventions for children affected by Sydenham's chorea.
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Affiliation(s)
- Kathleen G. Walker
- K. G. Walker, S25/26 Neurology OPD, Red Cross Children’s Hospital, Klipfontein Road, Rondebosch, 7700 Western Cape, South Africa
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van Immerzeel TD, van Gilst RM, Hartwig NG. Beneficial use of immunoglobulins in the treatment of Sydenham chorea. Eur J Pediatr 2010; 169:1151-4. [PMID: 20349351 PMCID: PMC2908459 DOI: 10.1007/s00431-010-1172-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 02/15/2010] [Indexed: 01/27/2023]
Abstract
This double case report indicates that treatment with intravenous immunoglobulins (IVIG) is effective in patients with Sydenham chorea (SC). SC is a rare but impressive clinical manifestation following streptococcal infection. This movement disorder characterised by chorea, emotional lability and muscle weakness, is one of the major criteria of acute rheumatic fever. Treatment of SC is typically limited to supportive care and palliative medications. Curative treatment is still in the experimental stage. Recent research on patients with SC proved that antibodies against the group A streptococcus cross-react with epitopes of neurons in the basal ganglia, namely, intracellular tubulin and extracellular lysoganglioside. Therefore, immune modulating therapy by means of prednisone, plasma exchange and IVIG are mentioned in the literature as possible effective treatment. Beneficial effect of IVIG has been shown in several diseases with molecular mimicry as the underlying pathophysiology. In this paper, we describe two girls aged 11 and 13 years, respectively, who presented with SC having severe disabilities in their daily live. We treated both patients with IVIG 400 mg/kg/day for 5 days. Treatment was tolerated well and had a pronounced positive effect. Shortly after the drug was administered, all signs and symptoms disappeared in both patients. Based upon these patients, we highlight IVIG as a serious treatment option for SC.
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Affiliation(s)
- Tabitha D van Immerzeel
- Paediatric Department, Van Weel Bethesda Ziekenhuis, Stationsweg 22, 3247 BW Dirksland, The Netherlands.
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