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Bernstein GA, Khan MH, Freese RL, Manko C, Silverman M, Ahmed S, Farhadian B, Ma M, Thienemann M, Murphy TK, Frankovich J. Psychometric Properties of the PANS 31-Item Symptom Rating Scale. J Child Adolesc Psychopharmacol 2024; 34:157-162. [PMID: 38536004 PMCID: PMC11040192 DOI: 10.1089/cap.2023.0088] [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] [Indexed: 04/14/2024]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by sudden onset of obsessive-compulsive disorder and/or eating restriction with associated neuropsychiatric symptoms from at least two of seven categories. The PANS 31-Item Symptom Rating Scale (PANS Rating Scale) was developed to identify and measure the severity of PANS symptoms. The objective of this study was to define the psychometric properties of the PANS Rating Scale. Methods: Children with PANS (N = 135) and their parents participated. Parents completed the PANS Rating Scale and other scales on Research Electronic Data Capture. The PANS Rating Scale includes 31 items that are rated on a Likert scale from 0 = none to 4 = extreme. Pearson's correlations were run between the PANS Total score and scores on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Yale Global Tic Severity Scale (YGTSS), Modified Overt Aggression Scale (MOAS), Columbia Impairment Scale (CIS), PANS Global Impairment Score (GIS), and Children's Global Assessment Scale (CGAS). Results: Convergent validity was supported by significant correlations between the PANS Total and scores on the CY-BOCS, YGTSS, MOAS, CIS, GIS, and CGAS. The largest correlations were with measures of functional impairment: PANS Total and CIS (r = 0.81) and PANS Total and GIS (r = 0.74). Cronbach's alpha was 0.89 which demonstrates strong internal consistency of the 31 items. PANS Total score was significantly higher in children in a flare of their neuropsychiatric symptoms compared to children who were not in a flare. Conclusions: This study provides preliminary support for the PANS Rating Scale as a valid research instrument with good internal consistency. The PANS Rating Scale appears to be a useful measure for assessing children with PANS.
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Affiliation(s)
- Gail A. Bernstein
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Maroof H. Khan
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rebecca L. Freese
- Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cindy Manko
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sana Ahmed
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Bahare Farhadian
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Meiqian Ma
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tanya K. Murphy
- Department of Pediatrics, University of South Florida, St Petersburg, Florida, USA
| | - Jennifer Frankovich
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
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Masterson EE, Gavin JM. Baseline characteristics of children in the International PANS Registry (IPR) Epidemiology Study. BMJ Open 2024; 14:e072743. [PMID: 38267248 PMCID: PMC10824037 DOI: 10.1136/bmjopen-2023-072743] [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: 02/13/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024] Open
Abstract
PURPOSE The International PANS Registry (IPR) Epidemiology Study is a registry-based, longitudinal study. We designed this study to improve phenotyping and characterisation of children with paediatric acute-onset neuropsychiatric syndrome (PANS) and PANS-like features and facilitate multidisciplinary and translational health research. This cohort provides new opportunities to address unresolved research questions related to the broad spectrum of heterogenous PANS-like conditions. PARTICIPANTS Inclusion in the IPR Epidemiology Study remains open indefinitely via IPR enrolment online. Participants include children with PANS or who have PANS-like features and their healthy siblings. We collected cross-sectional survey data based on parent report, including details on phenotypic traits and characteristics that, to our knowledge, have not been previously collected for this patient population. We describe the baseline characteristics of cases and their healthy siblings here. FINDINGS TO DATE The IPR Epidemiology Study currently includes 1781 individuals (1179 cases, 602 siblings; from 1010 households). Many households include a sibling (n=390, 39%) and some include multiple cases (n=205, 20%). Mean enrolment age was 11.3±4.3 years for cases and 10.1±5.3 for siblings. Leading PANS-like features include anxiety (94%), emotional lability (92%) and obsessions (90%). Onsets were sudden and dramatic (27%), gradual with a subsequent sudden and dramatic episode (68%) or a gradual progression (5%). The mean age at early signs/symptom onset was 4 years and 7 years at sudden and dramatic increases, respectively. Infection/illness was the most common suspected symptom trigger (84%). Nearly all cases had been treated with antibiotics (88%) and/or non-steroidal anti-inflammatory drugs (79%). Parents reported immune-related conditions in cases (18%) and their nuclear, biological family (48%; 39% in biological mothers). FUTURE PLANS Future plans include increasing sample size, collecting longitudinal survey data, recruiting appropriate study controls and expanding the scope of the database, prioritising medical record data integration and creating a linked biorepository. Secondary data analyses will prioritise identifying subgroups by phenotypic traits, maternal health and disease characteristics.
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Affiliation(s)
- Erin E Masterson
- Environmental and Occupational Health Sciences, University of Washington, Seattle, Wisconsin, USA
| | - Jessica M Gavin
- Pediatric Research and Advocacy Initiative, Richmond, Virginia, USA
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Gagliano A, Carta A, Tanca MG, Sotgiu S. Pediatric Acute-Onset Neuropsychiatric Syndrome: Current Perspectives. Neuropsychiatr Dis Treat 2023; 19:1221-1250. [PMID: 37251418 PMCID: PMC10225150 DOI: 10.2147/ndt.s362202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) features a heterogeneous constellation of acute obsessive-compulsive disorder (OCD), eating restriction, cognitive, behavioral and/or affective symptoms, often followed by a chronic course with cognitive deterioration. An immune-mediated etiology is advocated in which the CNS is hit by different pathogen-driven (auto)immune responses. This narrative review focused on recent clinical (ie, diagnostic criteria, pre-existing neurodevelopmental disorders, neuroimaging) and pathophysiological (ie, CSF, serum, genetic and autoimmune findings) aspects of PANS. We also summarized recent points to facilitate practitioners with the disease management. Relevant literature was obtained from PubMed database which included only English-written, full-text clinical studies, case reports, and reviews. Among a total of 1005 articles, 205 were pertinent to study inclusion. Expert opinions are converging on PANS as the effect of post-infectious events or stressors leading to "brain inflammation", as it is well-established for anti-neuronal psychosis. Interestingly, differentiating PANS from either autoimmune encephalitides and Sydenham's chorea or from alleged "pure" psychiatric disorders (OCD, tics, Tourette's syndrome), reveals several overlaps and more analogies than differences. Our review highlights the need for a comprehensive algorithm to help both patients during their acute distressing phase and physicians during their treatment decision. A full agreement on the hierarchy of each therapeutical intervention is missing owing to the limited number of randomized controlled trials. The current approach to PANS treatment emphasizes immunomodulation/anti-inflammatory treatments in association with both psychotropic and cognitive-behavioral therapies, while antibiotics are suggested when an active bacterial infection is established. A dimensional view, taking into account the multifactorial origin of psychiatric disorders, should suggest neuro-inflammation as a possible shared substrate of different psychiatric phenotypes. Hence, PANS and PANS-related disorders should be considered as a conceptual framework describing the etiological and phenotypical complexity of many psychiatric disorders.
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Affiliation(s)
- Antonella Gagliano
- Department of Health Science, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Alessandra Carta
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
| | - Marcello G Tanca
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Stefano Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
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Lubarski K, Mania A, Michalak S, Osztynowicz K, Mazur-Melewska K, Figlerowicz M. The Coexistence of Antibodies to Neuronal Cell and Synaptic Receptor Proteins, Gangliosides and Selected Neurotropic Pathogens in Neurologic Disorders in Children. Diagnostics (Basel) 2023; 13:diagnostics13071274. [PMID: 37046492 PMCID: PMC10093427 DOI: 10.3390/diagnostics13071274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Various primarily non-autoimmune neurological disorders occur synchronously with autoantibodies against tissues in the nervous system. We aimed to assess serum and cerebrospinal fluid (CSF) autoantibodies in children with neurologic disorders. To find new diagnostic tools, we compared the laboratory and clinical findings between the distinguished groups. Retrospectively, 508 patients were divided into six subgroups: neuroinfections, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, neurologic autoimmune and demyelinating diseases, epilepsy, pervasive developmental disorders and other patients. We analysed serum anti-aquaporin-4, antiganglioside, neuronal antinuclear and cytoplasmic antibodies, as well as antibodies against surface neuronal and synaptic antigens in the CSF and serum. We involved available demographic and clinical data. Autoantibodies appeared in 165 (32.3%) children, with 24 showing multiple types of them. The most common were anti-neuroendothelium (anti-NET), anti-N-Methyl-D-Aspartate receptor (anti-NMDAr), anti-glial fibrillary acidic protein and anti-myelin antibodies bothering 46/463 (9.9%), 32/343 (9.4%), 27/463 (5.8%) and 27/463 (5.8%), respectively. Anti-NET and anti-NMDAr antibodies appeared more frequently in children with autoimmunity (p = 0.017; p < 0.001, respectively), increasing the autoimmune disease risk (OR = 2.18, 95% CI 1.13–13.97; OR = 3.91, 95% CI 1.86–8.22, respectively). Similar pathomechanisms appeared in diseases of different aetiology with clinical spectrums mimicking each other, so we proposed the model helping to diagnose autoimmune disease. We proved the influence of age, living place and medical history on the final diagnosis.
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Affiliation(s)
- Karol Lubarski
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
| | - Anna Mania
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
| | - Sławomir Michalak
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, 49 Przybyszewskiego St., 60-355 Poznan, Poland
| | - Krystyna Osztynowicz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, 49 Przybyszewskiego St., 60-355 Poznan, Poland
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
| | - Magdalena Figlerowicz
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
- Correspondence:
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Hoffman KL, Cano-Ramírez H. Pediatric neuropsychiatric syndromes associated with infection and microbiome alterations: clinical findings, possible role of the mucosal epithelium, and strategies for the development of new animal models. Expert Opin Drug Discov 2022; 17:717-731. [PMID: 35543072 DOI: 10.1080/17460441.2022.2074396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Subsets of pediatric obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) respectively have been associated with respiratory tract infections and alterations in the intestinal microbiome. Pediatric Acute-onset Neuropsychiatric Syndromes (PANS) refers to the sudden onset of neuropsychiatric symptoms that are triggered by several different infectious and non-infectious factors. Clinical studies and animal modeling are consistent with the proposal that inflammation plays an important etiological role in PANS, as well as in ASD associated with gut dysbiosis. AREAS COVERED The authors provide an overview of clinical studies of PANS and ASD associated with gastrointestinal symptoms, as well as the current strategies for studying these syndromes in rodent models. Finally, the authors highlight similarities between these syndromes that may provide clues to common etiological mechanisms. EXPERT OPINION Although data from existing animal models are consistent with an important role for anti-neuronal antibodies in PANS triggered by GAS infection, we lack models for identifying pathophysiological mechanisms of PANS associated with other infectious and non-infectious triggers. The authors propose a strategy for developing such models that incorporates known vulnerability and triggering factors for PANS into the modeling process. This novel strategy should expand our understanding of the pathophysiology of PANS, as well as facilitate the development of new pharmacological treatments for PANS and related syndromes.
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Affiliation(s)
- Kurt Leroy Hoffman
- Centro de Investigación en Reproducción Animal Dr. Carlos Beyer Flores (CIRA), Universidad Autónoma de Tlaxcala - Centro de Investigación de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN)
| | - Hugo Cano-Ramírez
- Centro de Investigación en Reproducción Animal Dr. Carlos Beyer Flores (CIRA), Universidad Autónoma de Tlaxcala - Centro de Investigación de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN)
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Hansen N, Luedecke D, Malchow B, Lipp M, Vogelgsang J, Timäus C, Zindler T, Gingele S, Kühn S, Gallinat J, Wiedemann K, Denk J, Moschny N, Fiehler J, Skripuletz T, Riedel C, Wattjes MP, Zerr I, Esselmann H, Poustka L, Karow A, Hartmann H, Frieling H, Bleich S, Wiltfang J, Neyazi A. Autoantibody-associated psychiatric syndromes in children: link to adult psychiatry. J Neural Transm (Vienna) 2021; 128:735-747. [PMID: 34057596 PMCID: PMC8205901 DOI: 10.1007/s00702-021-02354-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/13/2021] [Indexed: 01/18/2023]
Abstract
Studies show that psychiatric symptoms in adults and children are sometimes associated with serum neural autoantibodies. The significance of serum neural autoantibodies associated with psychiatric symptoms in children remains often unclear, but might be relevant for the extent and occurrence of psychiatric disease manifestation in later life, as well as therapy and outcome. For this narrative review, we sought articles listed in PubMed and published between 1988 and 2020 addressing the maternal-fetal transfer of neural autoantibodies and psychiatric disorders associated with serum neural autoantibodies. We identified six major subgroups of psychiatric disorders in children that are associated with serum neural autoantibodies: patients with attentional deficit hyperactivity disorder, autism spectrum disorder, obsessive compulsive disorder, Gilles de la Tourette syndrome, psychosis and catatonia. Furthermore, we summarized study findings from maternal-fetal transfer of Contactin-associated protein-like 2, N-methyl-D-aspartate receptor and fetal brain autoantibodies associated with behavioral effects in animals and humans. We hypothesize that the maternal transfer of serum neuronal autoantibodies during or after birth could result (1) in the ignition of an autoimmune-mediated inflammation having neurodevelopmental consequences for their children (autoimmune-priming-attack hypothesis) and (2) has a potential impact on the later manifestation of psychiatric disorders. Through this narrative review, we propose a diagnostic pathway for the clinical diagnosis of a potentially autoimmune origin of psychiatric symptoms in children while considering recent guidelines.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany.
| | - Daniel Luedecke
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Michael Lipp
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Jonathan Vogelgsang
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Charles Timäus
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Tristan Zindler
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Klaus Wiedemann
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Johannes Denk
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Christian Riedel
- Department of Neuroradiology, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Mike P Wattjes
- Department of Neuroradiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Inga Zerr
- Department of Neurology, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Hermann Esselmann
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Luise Poustka
- Department of Childhood and Adolescence Psychiatry, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Anne Karow
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
- German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075, Göttingen, Germany
- Neurosciences and Signaling Group, Department of Medical Sciences, Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Alexandra Neyazi
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
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Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder. Psychiatry Res 2021; 299:113858. [PMID: 33770712 DOI: 10.1016/j.psychres.2021.113858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/06/2021] [Indexed: 12/28/2022]
Abstract
Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.
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Prato A, Gulisano M, Scerbo M, Barone R, Vicario CM, Rizzo R. Diagnostic Approach to Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS): A Narrative Review of Literature Data. Front Pediatr 2021; 9:746639. [PMID: 34778136 PMCID: PMC8580040 DOI: 10.3389/fped.2021.746639] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/24/2021] [Indexed: 12/12/2022] Open
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinical conditions characterized by the sudden onset of obsessive-compulsive disorder and/or tics, often accompanied by other behavioral symptoms in a group of children with streptococcal infection. PANDAS-related disorders, including pediatric acute-onset neuropsychiatric syndrome (PANS), childhood acute neuropsychiatric symptoms (CANS), and pediatric infection triggered autoimmune neuropsychiatric disorders (PITANDs), have also been described. Since first defined in 1998, PANDAS has been considered a controversial diagnosis. A comprehensive review of the literature was performed on PubMed and Scopus databases, searching for diagnostic criteria and diagnostic procedures of PANDAS and related disorders. We propose a test panel to support clinicians in the workout of PANDAS/PANS patients establishing an appropriate treatment. However, further studies are needed to improve our knowledge on these acute-onset neuropsychiatric conditions.
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Affiliation(s)
- Adriana Prato
- Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy.,Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Mariangela Gulisano
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Miriam Scerbo
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Rita Barone
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Carmelo M Vicario
- Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy
| | - Renata Rizzo
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
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Murciano M, Biancone DM, De Luca F, Piras Marafon D, Guido CA, Spalice A. Breastfeeding in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Italian Observational Study. Front Pediatr 2021; 9:682108. [PMID: 34307255 PMCID: PMC8295522 DOI: 10.3389/fped.2021.682108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a condition defined by sudden onset of obsessive-compulsive symptoms and/or severe eating restrictions, along with at least two other cognitive, behavioral, or neurological symptoms. Its pathogenesis is unknown but it seems triggered by infections, metabolic disturbances, and other inflammatory reactions. PANS represents a neurodevelopmental problem and infant feeding can play a role. Breast milk is the ideal food for infants and influences children's brain, cognitive, and socio-emotional development. Methods: We enrolled 52 children diagnosed with PANS. We interviewed their parents in order to investigate perinatal history, infant feeding, neurologic development, and confounding factors like socio-economic status and region of origin. We subgrouped PANS patients into three subsets: those who only received human milk (HMO), those who only received infant formula, and those who received mixed feeding. Results: The cohort is composed of 78.9% males, with a median age of 11 years (range 7-17). We found some neurodevelopmental problems (13.5%): walking disorders, ASD, ADHD, oppositional attitude, and delayed psychomotor development. We found scholar performance deficits (25%), including language problems like dysgraphia, dyslexia, and dyscalculia. The achievement of some milestones in the development of the infant is affected in 73.1% of cases. Breastfeeding is not homogeneously practiced in Italy because of social, economic, and cultural phenomena. The richest and the poorest families (100%) in the sample choose breastfeeding, probably with a different approach and for different reasons (awareness or need). In the group of PANS patients fed with HMO, compared to the rest of the patients, we registered fewer cases of growth problems (0 vs. 12.9%; p = 0.14), school performance problems or the need for school support (19.1% vs. 29%; p = 0.42), and a delay in the age of babbling/speaking (range 4-20 vs. 7-36 months; p = 0.066). Conclusion: This is the first study that investigates the role of breastfeeding in the development of PANS. Promoting breastfeeding is important in the general population and also in PANS patients because it has an important social and global health impact, also during adult life. Further studies with a bigger population are needed to investigate the mechanisms underlying PANS and the role that breastfeeding may play in their short- and long-term neurodevelopment.
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Affiliation(s)
- Manuel Murciano
- Emergency Paediatric Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Davide Maria Biancone
- Child Neurology Division, Department of Pediatrics, "Sapienza" University of Rome, Rome, Italy
| | - Francesca De Luca
- Child Neurology Division, Department of Pediatrics, "Sapienza" University of Rome, Rome, Italy
| | | | - Cristiana Alessia Guido
- Child Neurology Division, Department of Pediatrics, "Sapienza" University of Rome, Rome, Italy.,Department of Developmental and Social Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, "Sapienza" University of Rome, Rome, Italy
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Gagliano A, Puligheddu M, Ronzano N, Congiu P, Tanca MG, Cursio I, Carucci S, Sotgiu S, Grossi E, Zuddas A. Artificial Neural Networks Analysis of polysomnographic and clinical features in Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): from sleep alteration to "Brain Fog". Nat Sci Sleep 2021; 13:1209-1224. [PMID: 34326674 PMCID: PMC8315772 DOI: 10.2147/nss.s300818] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/17/2021] [Indexed: 02/05/2023] Open
Abstract
STUDY OBJECTIVES PANS (pediatric acute onset neuropsychiatric syndrome) is thought to be the result of several mechanisms and multiple etiologies, ranging from endocrine/metabolic causes to postinfectious autoimmune and neuroinflammatory disorders. Sleep disorders represent one of the most frequent manifestations of PANS, involving around 80% of patients. The present study describes the clinical and polysomnographic features in a group of PANS children identifying the relationships between sleep disorders and other PANS symptoms. METHODS All participants underwent a clinical evaluation including comprehensive sleep history, polysomnography, cognitive assessment and blood chemistry examination. A data mining approach with fourth-generation artificial neural networks has been used in order to discover subtle trends and associations among variables. RESULTS Polysomnography showed abnormality in 17 out of 23 recruited subjects (73.9%). In particular, 8/17 children (47%) had ineffective sleep, 10/17 (58.8%) fragmented sleep, 8/17 (47.1%) periodic limb movement disorder (PLMD) and 11/17 (64.7%) REM-sleep without atonia (RSWA). Most subjects presented more than one sleep disturbances. Notably, among the 19/23 patients diagnosed with Tic/Tourette disorder, 8/19 (42.1%) show PLMD and 10/19 (52.6%) RSWA. Artificial neural network methodology and the auto-contractive map exploited the links among the full spectrum of variables revealing the simultaneous connections among them, facing the complexity of PANS phenotype. CONCLUSION Disordered sleep represents, for prevalence and impact on quality of life, a cardinal symptom in patients with PANS. Thus, considering the weight of sleep disturbances on diagnosis and prognosis of PANS, we could consider the possibility of including them among the major diagnostic criteria.
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Affiliation(s)
- Antonella Gagliano
- Child & Adolescent Neuropsychiatry Unit, “Azienda Ospedaliera Brotzu” Hospital Trust, Cagliari, Italy
| | - Monica Puligheddu
- Sleep Disorder Centre, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Correspondence: Monica Puligheddu Sleep Disorder Research Center, Department of Medical Science and Public Health, University of Cagliari, asse didattico E. SS 554 bivio Sestu, Monserrato, Cagliari, 09042, ItalyTel +0706754952 Email
| | - Nadia Ronzano
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Patrizia Congiu
- Sleep Disorder Centre, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Marcello Giuseppe Tanca
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Ida Cursio
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Sara Carucci
- Child & Adolescent Neuropsychiatry Unit, “Azienda Ospedaliera Brotzu” Hospital Trust, Cagliari, Italy
| | - Stefano Sotgiu
- Child Neuropsychiatry Unit, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, Sassari, Italy
| | - Enzo Grossi
- Autism Research Unit, Villa Santa Maria Foundation, Como, Italy
| | - Alessandro Zuddas
- Child & Adolescent Neuropsychiatry Unit, “Azienda Ospedaliera Brotzu” Hospital Trust, Cagliari, Italy
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
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Szechtman H, Harvey BH, Woody EZ, Hoffman KL. The Psychopharmacology of Obsessive-Compulsive Disorder: A Preclinical Roadmap. Pharmacol Rev 2020; 72:80-151. [PMID: 31826934 DOI: 10.1124/pr.119.017772] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This review evaluates current knowledge about obsessive-compulsive disorder (OCD), with the goal of providing a roadmap for future directions in research on the psychopharmacology of the disorder. It first addresses issues in the description and diagnosis of OCD, including the structure, measurement, and appropriate description of the disorder and issues of differential diagnosis. Current pharmacotherapies for OCD are then reviewed, including monotherapy with serotonin reuptake inhibitors and augmentation with antipsychotic medication and with psychologic treatment. Neuromodulatory therapies for OCD are also described, including psychosurgery, deep brain stimulation, and noninvasive brain stimulation. Psychotherapies for OCD are then reviewed, focusing on behavior therapy, including exposure and response prevention and cognitive therapy, and the efficacy of these interventions is discussed, touching on issues such as the timing of sessions, the adjunctive role of pharmacotherapy, and the underlying mechanisms. Next, current research on the neurobiology of OCD is examined, including work probing the role of various neurotransmitters and other endogenous processes and etiology as clues to the neurobiological fault that may underlie OCD. A new perspective on preclinical research is advanced, using the Research Domain Criteria to propose an adaptationist viewpoint that regards OCD as the dysfunction of a normal motivational system. A systems-design approach introduces the security motivation system (SMS) theory of OCD as a framework for research. Finally, a new perspective on psychopharmacological research for OCD is advanced, exploring three approaches: boosting infrastructure facilities of the brain, facilitating psychotherapeutic relearning, and targeting specific pathways of the SMS network to fix deficient SMS shut-down processes. SIGNIFICANCE STATEMENT: A significant proportion of patients with obsessive-compulsive disorder (OCD) do not achieve remission with current treatments, indicating the need for innovations in psychopharmacology for the disorder. OCD may be conceptualized as the dysfunction of a normal, special motivation system that evolved to manage the prospect of potential danger. This perspective, together with a wide-ranging review of the literature, suggests novel directions for psychopharmacological research, including boosting support systems of the brain, facilitating relearning that occurs in psychotherapy, and targeting specific pathways in the brain that provide deficient stopping processes in OCD.
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Affiliation(s)
- Henry Szechtman
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada (H.S.); SAMRC Unit on Risk Resilience in Mental Disorders, Department of Psychiatry, University of Cape Town, and Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North-West University (Potchefstroom Campus), Potchefstroom, South Africa (B.H.H.); Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada (E.Z.W.); and Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, Mexico (K.L.H.)
| | - Brian H Harvey
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada (H.S.); SAMRC Unit on Risk Resilience in Mental Disorders, Department of Psychiatry, University of Cape Town, and Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North-West University (Potchefstroom Campus), Potchefstroom, South Africa (B.H.H.); Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada (E.Z.W.); and Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, Mexico (K.L.H.)
| | - Erik Z Woody
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada (H.S.); SAMRC Unit on Risk Resilience in Mental Disorders, Department of Psychiatry, University of Cape Town, and Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North-West University (Potchefstroom Campus), Potchefstroom, South Africa (B.H.H.); Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada (E.Z.W.); and Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, Mexico (K.L.H.)
| | - Kurt Leroy Hoffman
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada (H.S.); SAMRC Unit on Risk Resilience in Mental Disorders, Department of Psychiatry, University of Cape Town, and Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North-West University (Potchefstroom Campus), Potchefstroom, South Africa (B.H.H.); Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada (E.Z.W.); and Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, Mexico (K.L.H.)
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12
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Vidal V, McAllister A, DeThorne L. Communication Profile of a Minimally Verbal School-Age Autistic Child: A Case Study. Lang Speech Hear Serv Sch 2020; 51:671-686. [PMID: 32392446 DOI: 10.1044/2020_lshss-19-00021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose The present clinical focus draws on an intrinsic case study to provide a thick description of the communication profile of John, a 9-year-old minimally verbal autistic student. Method Specifically, traditional behavioral assessments, classroom video observations, and semistructured interviews were used to gather information regarding John's communication profile and potential sensory-motor differences. Results Convergent evidence indicated that John's expressive profile was characterized by single words, emergent word combinations, some conventional gestures, and a low frequency of communicative initiations. Concomitant language comprehension challenges and poor intelligibility associated with motor speech impairment were also indicated. His sensory-motor profile was marked by fine motor impairment, relative strengths in gross motor abilities, and sensory differences across visual, hearing, and tactile modalities. Conclusion Direct implications for supporting minimally verbal autistic students like John include the need to (a) consider sensory-motor influences on social interaction and (b) support flexible use of multimodal communication resources, including augmentative and alternative communication. Supplemental Material https://doi.org/10.23641/asha.12202448.
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Affiliation(s)
- Verónica Vidal
- Department of Speech-Language Pathology, Universidad de los Andes, Santiago, Chile
| | - Anita McAllister
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Laura DeThorne
- Department of Speech, Language and Hearing Sciences, Western Michigan University, Kalamazoo
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13
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Becker JE, Smith JR, Hazen EP. Pediatric Consultation-Liaison Psychiatry: An Update and Review. PSYCHOSOMATICS 2020; 61:467-480. [PMID: 32482345 PMCID: PMC7194908 DOI: 10.1016/j.psym.2020.04.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 12/11/2022]
Abstract
Background In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care. Methods In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care. Conclusion The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.
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Affiliation(s)
- Jessica E Becker
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Joshua R Smith
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Eric P Hazen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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14
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The speed of progression towards obsessive-compulsive disorder. J Affect Disord 2020; 264:181-186. [PMID: 32056748 DOI: 10.1016/j.jad.2019.12.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/17/2019] [Accepted: 12/09/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is current interest in the elaboration of early intervention programs for obsessive-compulsive disorder (OCD). To this end, it is important to investigate the speed of progression from subthreshold symptoms to diagnosable OCD. In this study, we have retrospectively investigated the speed of progression towards full-blown OCD and sociodemographic and clinical factors associated with a faster transition. METHODS Patients enrolled in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (N = 954) were interviewed with a comprehensive assessment battery that included the interval (in years) between the onset of subthreshold OCD symptoms and the onset of full-blown OCD. RESULTS It took a median of 7 years (interquartile range: 2-13 years) for subthreshold symptoms to convert to diagnosable OCD. Faster OCD onset was associated with lower age at the time of assessment, male gender, being in new romantic states as precipitants for compulsions, greater severity of sexual/religious symptoms and lower severity of hoarding and YBOCS compulsions severity scores, greater rates of generalized anxiety disorder and agoraphobia without panic disorder, and negative family history for OCD. LIMITATIONS The retrospective design of this study allowed for susceptibility to memory bias about age at onset of OCD symptoms. We were unable to capture progressions taking less than 12 months. CONCLUSIONS We could identify a specific phenotype that was more likely to escalate rapidly to clinical levels within this large clinical sample. This phenomenon may be particularly relevant in the context of selecting individuals for early intervention initiatives in situations when resources are scarce.
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15
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McFarland G, La Joie E, Thomas P, Lyons-Weiler J. Acute exposure and chronic retention of aluminum in three vaccine schedules and effects of genetic and environmental variation. J Trace Elem Med Biol 2020; 58:126444. [PMID: 31846784 DOI: 10.1016/j.jtemb.2019.126444] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/12/2019] [Accepted: 12/03/2019] [Indexed: 01/22/2023]
Abstract
Like the mechanisms of action as adjuvants, the pharmacodynamics of injected forms of aluminum commonly used in vaccines are not well-characterized, particularly with respect to how differences in schedules impact accumulation and how factors such as genetics and environmental influences on detoxification influence clearance. Previous modeling efforts are based on very little empirical data, with the model by Priest based on whole-body clearance rates estimated from a study involving a single human subject. In this analysis, we explore the expected acute exposures and longer-term whole-body accumulation/clearance across three vaccination schedules: the current US Centers for Disease Control and Prevention (CDC) schedule, the current CDC schedule using low aluminum or no aluminum vaccines, and Dr. Paul Thomas' "Vaccine Friendly Plan" schedule. We then study the effects of an implicit assumption of the Priest model on whether clearance dynamics from successive doses are influenced by the current level of aluminum or modeled by the assumption that a new dose has its own whole-body dynamics "reset" on the day of injection. We model two additional factors: variation (deficiency) in aluminum detoxification, and a factor added to the Priest equation to model the potential impact of aluminum itself on cellular and whole-body detoxification. These explorations are compared to a previously estimated pediatric dose limit (PDL) of whole-body aluminum exposure and provide a new statistic: %alumTox, the (expected) percentage of days (or weeks) an infant is in aluminum toxicity, reflecting chronic toxicity. We show that among three schedules, the CDC schedule results in the highest %alumTox regardless of model assumptions, and the Vaccine Friendly Plan schedule, which avoids >1 ACV per office visit results in the lowest (expected) %alumTox. These results are conservative, as the MSL is derived from data used by FDA to estimate safety of aluminum in adult humans. These results demonstrate high potential utility of modeling variation in patient responses to aluminum. More empirical data from individuals who are suspected of being intolerant of aluminum from vaccines, evidenced by high aluminum retention, neurodevelopmental disorders and/or a myriad of chronic illnesses would help answer questions on whether the model predictions can be used to estimate parameter values tied to genetic factors including genomic sequence variation and family history of chronic illnesses tied to aluminum exposure.
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Affiliation(s)
- Grant McFarland
- The Institute for Pure and Applied Knowledge, Pittsburgh, PA, 15101, United States
| | - Elaine La Joie
- The Institute for Pure and Applied Knowledge, Pittsburgh, PA, 15101, United States
| | - Paul Thomas
- Integrative Pediatrics, Portland, OR, 97225, United States
| | - James Lyons-Weiler
- The Institute for Pure and Applied Knowledge, Pittsburgh, PA, 15101, United States.
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16
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Lepri G, Rigante D, Bellando Randone S, Meini A, Ferrari A, Tarantino G, Cunningham MW, Falcini F. Clinical-Serological Characterization and Treatment Outcome of a Large Cohort of Italian Children with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2019; 29:608-614. [PMID: 31140830 DOI: 10.1089/cap.2018.0151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: Pediatric autoimmune neuropsychiatric disorder associated with Streptococcus pyogenes infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are emerging immune-mediated encephalopathies characterized by sudden onset of seemingly inexplicable complex neuropsychiatric symptoms, including obsessions, compulsions, and heterogeneous tics, which occur in children. Main goal of this study was to report our experience in a large cohort of Italian children affected by either PANDAS or PANS and treated long term with an antibiotic regimen similar to that used for acute rheumatic fever. Patients and Methods: The clinical charts of a cohort of 371 consecutive Italian children, 345 with PANDAS (93.0%) and 26 with PANS (7.0%), were retrospectively evaluated. Antistreptococcal, antinuclear antibodies, and serologic evaluation for a group of common autoantibodies and microbial agents were also assessed. A strict differential diagnosis with other autoimmune diseases displaying neuropsychiatric manifestations was performed. Results: Antistreptolysin O and anti-DNase B antibody titers were tested and were positive in all PANDAS subjects, but negative in PANS. Anti-Mycoplasma pneumoniae antibodies and anti-Epstein-Barr virus Nuclear Antigen antibodies were found positive in 11 (42.3%) and 5 (19.2%) patients with PANS, respectively. Among PANDAS cases, a clear streptococcal infection was clinically evident at the onset of neurological symptoms in only 74 patients (21.4%), whereas the relationship with Streptococcus pyogenes was confirmed by serologic tests in the other 271 (78.6%). All patients fulfilling the diagnostic criteria for PANDAS (n = 345) received amoxicillin/clavulanic acid for 10-21 days at diagnosis, while those who were diagnosed with PANS (n = 26) received treatment according to the causative agent. Thereafter, all PANDAS/PANS patients received prophylaxis with benzathine benzylpenicillin for an overall period of at least 5 years to prevent subsequent potential streptococcal infections. To date, 75.0% of PANDAS patients (n = 258) have shown an improvement of neurologic symptoms, mainly observed within 3-5 months of treatment for PANDAS cases, while 88.4% of PANS patients (n = 23) have improved after 6-12 months. Infection-related relapses of neurologic manifestations were observed in both PANDAS and PANS patients (n = 167 out of 371; 45% of the total cohort) in the long term. Conclusions: Our study has confirmed the usefulness of the preliminary diagnostic criteria for PANDAS and PANS, revealing also the importance of early diagnosis to reduce the risk of evolution toward disabling chronic neurologic sequelae. Long-term antibiotic prophylaxis has resulted in a substantial benefit to reduce neurological symptoms for the majority of PANDAS and PANS patients over a 7-year period.
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Affiliation(s)
- Gemma Lepri
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Bellando Randone
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
| | - Antonella Meini
- Department of Pediatrics, Unit of Immunology and Pediatric Rheumatology, University of Brescia, Spedali Civili, Brescia, Italy
| | - Alessandra Ferrari
- Department of Pediatrics, Unit of Immunology and Pediatric Rheumatology, University of Brescia, Spedali Civili, Brescia, Italy
| | - Giusyda Tarantino
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy
| | - Madeleine W Cunningham
- Department of Microbiology and Immunology, Biomedical Research Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Fernanda Falcini
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
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Williams KA. Defining paediatric acute-onset neuropsychiatric syndrome. THE LANCET. CHILD & ADOLESCENT HEALTH 2019; 3:134-135. [PMID: 30704876 DOI: 10.1016/s2352-4642(19)30021-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 06/09/2023]
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18
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Pediatric acute-onset neuropsychiatric syndrome (PANS) misdiagnosed as autism spectrum disorder. Immunol Lett 2018; 203:52-53. [PMID: 30222991 DOI: 10.1016/j.imlet.2018.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 12/28/2022]
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19
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Esawy MM, Shabana MA, Ali EF. Role of IL-6/IL-10 ratio in the diagnosis and in the assessment of the severity of obsessive-compulsive disorder. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s00580-018-2803-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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20
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Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev 2018; 86:51-65. [DOI: 10.1016/j.neubiorev.2018.01.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/10/2017] [Accepted: 01/01/2018] [Indexed: 12/25/2022]
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Stagi S, Lepri G, Rigante D, Matucci Cerinic M, Falcini F. Cross-Sectional Evaluation of Plasma Vitamin D Levels in a Large Cohort of Italian Patients with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. J Child Adolesc Psychopharmacol 2018; 28:124-129. [PMID: 29112476 DOI: 10.1089/cap.2016.0159] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are immune-mediated diseases characterized by obsessive-compulsive symptoms and/or tics triggered by group A Streptococcus infections. Despite the well-known action of 25-hydroxyvitamin D [25(OH)D] on different conditions driven by systemic inflammation, there are no data about the 25(OH)D status in patients with PANDAS. AIMS To evaluate plasma 25(OH)D levels in a large cohort of children and adolescents with PANDAS and comparing the results with healthy controls. METHODS We have evaluated plasma 25(OH)D levels in 179 Italian patients with PANDAS (49 females, 130 males, mean age at diagnosis: 101.4 ± 30.1 months) and in an age-, gender-, and body mass index-matched control group of 224 healthy subjects. RESULTS Patients with PANDAS have shown more frequently reduced 25(OH)D levels (<30 ng/mL) in comparison with controls (94.6% vs. 82.5%, p = 0.0007). Patients with PANDAS had also lower levels of 25(OH)D than controls (20.4 ± 6.9 ng/mL vs. 24.8 ± 7.3 ng/mL, p < 0.0001). This difference was observed during both winter (13.7 ± 3.25 ng/mL vs. 21.4 ± 5.9 ng/mL, p < 0.0001) and summer (21.8 ± 6.5 ng/mL vs. 32.5 ± 8.7 ng/mL, p < 0.0001). Notably, serum 25(OH)D levels correlated with both number of streptococcal (strep) infections before diagnosis of PANDAS (p < 0.005) and with infection recurrence (p < 0.005). CONCLUSIONS PANDAS patients have reduced 25(OH)D levels, which appear related to streptococcal infections and the probability of recurrence. Further long-term studies with higher number of patients are needed to investigate and confirm this relationship.
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Affiliation(s)
- Stefano Stagi
- 1 Department of Health Sciences, University of Florence , Florence, Italy
| | - Gemma Lepri
- 2 Rheumatology Section, Department of Internal Medicine, Transition Clinic, University of Florence , Florence, Italy
| | - Donato Rigante
- 3 Institute of Pediatrics , Fondazione Policlinico Universitario A. Gemelli, Università Cattolica Sacro Cuore, Rome, Italy
| | - Marco Matucci Cerinic
- 2 Rheumatology Section, Department of Internal Medicine, Transition Clinic, University of Florence , Florence, Italy
| | - Fernanda Falcini
- 2 Rheumatology Section, Department of Internal Medicine, Transition Clinic, University of Florence , Florence, Italy
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Obsessive-compulsive symptoms in adults with Lyme disease. Gen Hosp Psychiatry 2018; 51:85-89. [PMID: 29408088 DOI: 10.1016/j.genhosppsych.2018.01.009] [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: 09/20/2017] [Revised: 01/25/2018] [Accepted: 01/26/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study examined the phenomenology and clinical characteristics of obsessive compulsive symptoms (OCS) in adults diagnosed with Lyme disease. METHOD Participants were 147 adults aged 18-82 years (M = 43.81, SD = 12.98) who reported having been diagnosed with Lyme disease. Participants were recruited from online support groups for individuals with Lyme disease, and completed an online questionnaire about their experience of OCS, Lyme disease characteristics, and the temporal relationship between these symptoms. RESULTS OCS were common, with 84% endorsing clinically significant symptoms, 26% of which endorsed symptoms onset during the six months following their Lyme disease diagnosis and another 51% believed their symptoms were temporally related. Despite the common occurrence of OCS, only 44% of these participants self-identified these symptoms as problematic. Greater frequency of Lyme disease symptoms and disease-related impairment was related to greater OCS. In the majority of cases, symptom onset was gradual, and responded well to psychological and pharmacological treatment. Around half of participants (51%) reported at least some improvement in OCS following antibiotic treatment. CONCLUSIONS This study highlights the common co-occurrence of OCS in patients with Lyme disease. It is unclear whether OCS are due to the direct physiological effects of Lyme disease or associated immunologic response, a psychological response to illness, a functional somatic syndrome, or some combination of these.
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Fernandez TV, State MW, Pittenger C. Tourette disorder and other tic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2018; 147:343-354. [PMID: 29325623 DOI: 10.1016/b978-0-444-63233-3.00023-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tourette disorder is a developmental neuropsychiatric condition characterized by vocal and motor tics that can range in severity from mild to disabling. It represents one end of a spectrum of tic disorders and is estimated to affect 0.5-0.7% of the population. Accumulated evidence supports a substantial genetic contribution to disease risk, but the identification of genetic variants that confer risk has been challenging. Positive findings in candidate gene association studies have not replicated, and genomewide association studies have not generated signals of genomewide significance, in large part because of inadequate sample sizes. Rare mutations in several genes have been identified, but their causality is difficult to establish. As in other complex neuropsychiatric disorders, it is likely that Tourette disorder risk involves a combination of common, low-effect and rare, larger-effect variants in multiple genes acting together with environmental factors. With the ongoing collection of larger patient cohorts and the emergence of affordable high-throughput genomewide sequencing, progress is expected to accelerate in coming years.
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Affiliation(s)
- Thomas V Fernandez
- Child Study Center, Yale School of Medicine, New Haven, CT, United States
| | - Matthew W State
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, United States
| | - Christopher Pittenger
- Child Study Center, Yale School of Medicine, New Haven, CT, United States; Department of Psychiatry, Yale University, New Haven, CT, United States.
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Das S, Dileepan T, Johnson DR, Kaplan EL, Patrick Cleary P. Enzyme-linked immunosorbent assay for group A Streptococcal anti-DNase B in human sera, using recombinant proteins - Comparison to the DNA methyl green micromethod. J Immunol Methods 2017; 451:111-117. [PMID: 28939394 DOI: 10.1016/j.jim.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
Among the four known Streptococcal nucleases comprising of DNase A, B, C and D; DNase B is the most common, and determination of the levels of antibody to DNase B (ADB) is often used to confirm a clinical diagnosis of Streptococcus pyogenes/group A Streptococcal (GAS) infection. The commonly used assays for antibodies that neutralize DNase B or streptolysin O activity use partially purified antigens that often fail to detect antibody changes subsequent to culture documented infections. Therefore, an enzyme-linked immunosorbent assay (ELISA) was developed employing his-tagged recombinant DNase B as plate antigen for comparison to the commonly used DNA methyl green micromethod (DMGM). DNAs from various Streptococcal species were screened for presence of dnaseB gene by PCR. Measurements of ADB in sera collected from subjects belonging to different ages, and ethnic groups were used to compare the two methods. dnaseB was not detected by PCR in DNA samples isolated from different strains of group B (GBS), C (GCS) and G (GGS) Streptococci. The ADB based ELISA proved to be highly sensitive and more responsive to changes in antibody concentration than DMGM. Use of recombinant DNase B eliminates the variability associated with the enzyme, partially purified from Streptococcal culture supernatants from various commercial sources and may provide a more reliable source of antigen to a wider group of laboratories concerned with GAS diagnosis.
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Affiliation(s)
- Sarita Das
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA.
| | - T Dileepan
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA
| | - D R Johnson
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - E L Kaplan
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - P Patrick Cleary
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA.
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25
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Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part III-Treatment and Prevention of Infections. J Child Adolesc Psychopharmacol 2017; 27:594-606. [PMID: 36358106 PMCID: PMC9836684 DOI: 10.1089/cap.2016.0151] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) and its subset, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS), are emerging autoimmune encephalopathies of childhood. Management guidelines are needed. This article, from the PANS/PANDAS Consortium, presents a consensus management guideline for the infection components. Accompanying papers from the Consortium discuss psychiatric and immunomodulatory management. Methods: Literature was reviewed and integrated with the clinical experience of the authors to provide a set of practical guidelines. This article was submitted to all members of the PANS/PANDAS Consortium, and their additional comments were added. Results: The relationships between PANS and infections are reviewed. An approach to the retrospective diagnosis of group A streptococcal infection for an operational definition of PANDAS is proposed. An initial course of anti-streptococcal treatment is proposed for all newly diagnosed PANS cases. Chronic secondary antimicrobial prophylaxis is suggested for children with PANDAS who have severe neuropsychiatric symptoms or recurrent group A Streptococcus-associated exacerbations. Guidelines for children with non-streptococcal PANS include vigilance for streptococcal pharyngitis or dermatitis in the patient and close contacts. All patients with PANS or PANDAS should also be closely monitored for other intercurrent infections, including sinusitis and influenza. Intercurrent infections should be diagnosed and treated promptly according to current standard guidelines. A guideline for the assessment of infection at initial onset or during neuropsychiatric exacerbations is also presented. Standard immunizations and attention to vitamin D are encouraged. Data indicating limited utility of adenotonsillectomy and probiotics are presented. Conclusion: A working guideline for the management of infection issues in PANS and PANDAS, based on literature and expert opinion, is provided.
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Affiliation(s)
- Michael S Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Susan E Swedo
- Department of Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health (NIMH), Rockville, Maryland
| | - Mark S Pasternack
- Department of Pediatric Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
| | - Tanya K Murphy
- Director and Professor of Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida, St. Petersburg, Florida
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26
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Murphy TK, Brennan EM, Johnco C, Parker-Athill EC, Miladinovic B, Storch EA, Lewin AB. A Double-Blind Randomized Placebo-Controlled Pilot Study of Azithromycin in Youth with Acute-Onset Obsessive-Compulsive Disorder. J Child Adolesc Psychopharmacol 2017; 27:640-651. [PMID: 28358599 DOI: 10.1089/cap.2016.0190] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Sudden and severe onset of obsessive-compulsive disorder (OCD) may present secondary to infectious and/or immune-mediated triggers. We assessed the preliminary efficacy, tolerability, and safety of azithromycin compared with placebo in the treatment of OCD and associated symptoms in children with pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS Thirty-one youth aged 4-14 years (M = 8.26 ± 2.78 years, 62.5% male) were randomized to receive either placebo or azithromycin for 4 weeks (10 mg/kg up to 500 mg per day). Both groups were administered twice daily probiotics. The primary outcome, obsessive-compulsive symptom severity, was assessed using the OCD Clinical Global Impressions Severity (CGI-S OCD) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). RESULTS Participants in the azithromycin group (n = 17) showed significantly greater reductions in OCD severity on the CGI-S OCD than the placebo group (n = 14) posttreatment (p = 0.003), although there were no significant differences on the CY-BOCS. Significantly more participants in the azithromycin condition met treatment responder criteria on the CGI-I OCD at the end of week 4 (41.2%, n = 7) in comparison to the placebo group (7.1%, n = 1; p = 0.045). Tic severity moderated treatment response, with greater tic severity being associated with enhanced treatment response on the CGI-S OCD. Azithromycin was well tolerated with minimal adverse effects and no study dropouts due to side effects. However, the azithromycin group showed a trend toward significantly greater electrocardiography QTc (p = 0.060) at the end of week 4, and significantly more reports of loose or abnormal stools (p = 0.009). CONCLUSION This double blind pilot study suggests that azithromycin may be helpful in treating youth meeting the PANS diagnosis, especially those with elevated levels of both OCD and tic symptoms. Azithromycin was well tolerated, but the potential for cardiac risks suggests that additional monitoring may be needed to ensure safety.
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Affiliation(s)
- Tanya K Murphy
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida.,2 Department of Psychiatry & Behavioral Sciences, University of South Florida , St. Petersburg, Florida.,3 All Children's Hospital-Johns Hopkins Medicine , St. Petersburg, Florida
| | - Erin M Brennan
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida
| | - Carly Johnco
- 4 Department of Psychology-Macquarie University , Sydney, New South Wales
| | - Ellisa Carla Parker-Athill
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida
| | - Branko Miladinovic
- 5 Department of Internal Medicine, Center for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Eric A Storch
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida.,2 Department of Psychiatry & Behavioral Sciences, University of South Florida , St. Petersburg, Florida.,3 All Children's Hospital-Johns Hopkins Medicine , St. Petersburg, Florida.,6 Department of Health Policy and Management, University of South Florida , St. Petersburg, Florida.,7 Rogers Memorial Hospital , Tampa, Florida
| | - Adam B Lewin
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida.,2 Department of Psychiatry & Behavioral Sciences, University of South Florida , St. Petersburg, Florida
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27
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Chiarello F, Spitoni S, Hollander E, Matucci Cerinic M, Pallanti S. An expert opinion on PANDAS/PANS: highlights and controversies. Int J Psychiatry Clin Pract 2017; 21:91-98. [PMID: 28498087 DOI: 10.1080/13651501.2017.1285941] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES 'Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections' (PANDAS) identified a unique subgroup of patients with abrupt onset of obsessive compulsive disorder (OCD) symptoms clinically related to Streptococcus infection and accompanied by neuropsychological and motor symptoms. After almost 20 years, PANDAS has not been accepted as distinct disorder and new criteria for paediatric acute-onset neuropsychiatric syndrome (PANS) have been replaced it, highlighting the fact that several agents rather than only Streptococcus might be involved. METHODS Extensive review of the PANDAS/PANS literature was performed on PubMed. RESULTS Although antibiotics have been reported to be effective for acute and prophylactic phases in several uncontrolled studies and non-steroidal anti-inflammatory drugs (NSAID) are used during exacerbations, clinical multicenter trials are still missing. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT) are still the first line of recommendation for acute onset OCD spectrum. Immunological therapies should be restricted to a few cases. CONCLUSIONS While PANDAS has found no confirmation as a distinct syndrome, and it is not presented in DSM-5, patients with acute onset OCD spectrum, neurocognitive and motor symptoms should be evaluated for inflammatory, infective, immunological and metabolic abnormalities with a comprehensive diagnostic algorithm.
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Affiliation(s)
| | - Silvia Spitoni
- a Department of Neurofarba , University of Florence , Florence , Italy
| | - Eric Hollander
- b Department of Psychiatry , Icahn School of Medicine , NY , USA.,c Department of Psychiatry and Behavioral Sciences , Albert Einstein College of Medicine , NY , USA
| | - Marco Matucci Cerinic
- d Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Stefano Pallanti
- a Department of Neurofarba , University of Florence , Florence , Italy.,e Institute of Neuroscience , Florence , Italy
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Tona JT, Bhattacharjya S, Calaprice D. Impact of PANS and PANDAS Exacerbations on Occupational Performance: A Mixed-Methods Study. Am J Occup Ther 2017; 71:7103220020P1-7103220020P9. [PMID: 28422636 DOI: 10.5014/ajot.2017.022285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Pediatric acute-onset neuropsychiatric syndrome (PANS) includes pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and involves sudden-onset neuropsychiatric symptoms, including obsessions, compulsions, sensory difficulties, and dysgraphia after infection or other triggers. Our objective was to identify problems with areas of occupation, body functions, and performance skills during exacerbations. METHOD In this online retrospective study, based on the Occupational Therapy Practice Framework: Domain and Process (2nd ed.), we surveyed parents of 111 children with PANS. RESULTS Activities of daily living, math, handwriting, extracurricular activities, free play, organized sports, community and family social participation, higher level thinking, attention, memory, sequencing, emotional coping, and energy and drive were commonly affected during exacerbations. During exacerbations, children often required assistance and adaptation to remain functional or were unable to function at a typical level. CONCLUSION Children with PANS present with pervasive occupational performance needs during exacerbation. Children and families may benefit from accommodations to maximize function during this turbulent period.
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Affiliation(s)
- Janice Trigilio Tona
- Janice Trigilio Tona, PhD, OTR, is Clinical Assistant Professor and Program Director, Occupational Therapy Program, University at Buffalo, State University of New York;
| | - Sutanuka Bhattacharjya
- Sutanuka Bhattacharjya, MS, OTR, is Doctoral Candidate, Department of Rehabilitation Science, University at Buffalo, State University of New York
| | - Denise Calaprice
- Denise Calaprice, PhD, is President, Calaprice-Whitty Consulting, Inc., Blue Jay, CA
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29
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Limbrick J, Anari S. PANDAS in otolaryngology. Clin Otolaryngol 2017; 42:196. [DOI: 10.1111/coa.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2016] [Indexed: 11/29/2022]
Affiliation(s)
- J. Limbrick
- Queen Elizabeth Hospital Birmingham; Birmingham UK
| | - S. Anari
- Birmingham Heartlands Hospital; Birmingham UK
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30
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Kim Y, Ko TS, Yum MS, Jung AY, Kim HW. Obsessive-Compulsive Disorder Related to Mycoplasma-Associated Autoimmune Encephalopathy with Basal Ganglia Involvement. J Child Adolesc Psychopharmacol 2016; 26:400-2. [PMID: 26872247 DOI: 10.1089/cap.2015.0080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Yangsik Kim
- 1 Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine , Seoul, Korea
| | - Tae-Sung Ko
- 2 Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine , Seoul, Korea
| | - Mi-Sun Yum
- 2 Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine , Seoul, Korea
| | - Ah Young Jung
- 3 Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine , Seoul, Korea
| | - Hyo-Won Kim
- 1 Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine , Seoul, Korea
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31
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Şimşek Ş, Yüksel T, Çim A, Kaya S. Serum Cytokine Profiles of Children with Obsessive-Compulsive Disorder Shows the Evidence of Autoimmunity. Int J Neuropsychopharmacol 2016; 19:pyw027. [PMID: 27207913 PMCID: PMC5006199 DOI: 10.1093/ijnp/pyw027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/23/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Previous reports have described an association between autoimmunity and primary obsessive compulsive disorder. This study aimed to investigate any differences in the levels of T helper 1, 2, and 17 effector cell cytokines between obsessive compulsive disorder patients and the control group. METHODS The study included 34 children (23 males, 11 females), aged between 7 and 17 years, with a diagnosis of obsessive compulsive disorder prior to receiving treatment. The control group consisted of age- and gender-matched children. Study participants were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version, Children's Yale Brown Obsession Compulsion Scale, and Children's Depression Inventory. Cytokine serum concentrations were measured using the BD Cytometric Bead Array Human Th1/Th2/Th17 Cytokine Kit. RESULTS Interleukin-17A, tumor necrosis factor-α, and interleukin-2 levels were significantly higher in obsessive compulsive disorder patients, However, there was no correlation between T helper 1 and 17 cytokine profiles in the obsessive compulsive disorder group. The duration and severity of obsessive compulsive disorder symptoms were not significantly associated with interleukin-17A, interferon-gamma-γ, interleukin-10, interleukin-6, interleukin-4, and interleukin-2 levels. Interestingly, a negative correlation was found between tumor necrosis factor-α levels and Clinical Global Impression scores. CONCLUSIONS These findings suggest, in some cases, obsessive compulsive disorder may develop on a background of autoimmunity, and interleukin-2, tumor necrosis factor-α, and interleukin-17A may play a role in these autoimmune processes. Therefore, we believe it is important to investigate for obsessive compulsive disorder symptoms in patients with autoimmune disease and, conversely, autoimmune diseases in obsessive compulsive disorder patients.
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Affiliation(s)
- Şeref Şimşek
- Department of Child Psychiatry (Drs Şimşek and Yüksel), Department of Medical Genetics (Dr Çim), and Department of Immunology (Dr Kaya), Dicle University, Medical School, Diyarbakır, Turkey.
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32
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Cutforth T, DeMille MM, Agalliu I, Agalliu D. CNS autoimmune disease after Streptococcus pyogenes infections: animal models, cellular mechanisms and genetic factors. FUTURE NEUROLOGY 2016; 11:63-76. [PMID: 27110222 DOI: 10.2217/fnl.16.4] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Streptococcus pyogenes infections have been associated with two autoimmune diseases of the CNS: Sydenham's chorea (SC) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS). Despite the high frequency of pharyngeal streptococcus infections among children, only a small fraction develops SC or PANDAS. This suggests that several factors in combination are necessary to trigger autoimmune complications: specific S. pyogenes strains that induce a strong immune response toward the host nervous system; genetic susceptibility that predispose children toward an autoimmune response involving movement or tic symptoms; and multiple infections of the throat or tonsils that lead to a robust Th17 cellular and humoral immune response when untreated. In this review, we summarize the evidence for each factor and propose that all must be met for the requisite neurovascular pathology and behavioral deficits found in SC/PANDAS.
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Affiliation(s)
- Tyler Cutforth
- Department of Neurology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA
| | - Mellissa Mc DeMille
- Department of Pediatrics, Yale Child Health Research Center, Yale University School of Medicine, 464 Congress Avenue, Suite S208, New Haven, CT 06519, USA
| | - Ilir Agalliu
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave., Room 1315-B, Bronx, NY 10461, USA
| | - Dritan Agalliu
- Department of Neurology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA; Departments of Pathology & Cell Biology & Pharmacology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA
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33
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Dileepan T, Smith ED, Knowland D, Hsu M, Platt M, Bittner-Eddy P, Cohen B, Southern P, Latimer E, Harley E, Agalliu D, Cleary PP. Group A Streptococcus intranasal infection promotes CNS infiltration by streptococcal-specific Th17 cells. J Clin Invest 2015; 126:303-17. [PMID: 26657857 DOI: 10.1172/jci80792] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 11/05/2015] [Indexed: 12/20/2022] Open
Abstract
Group A streptococcal (GAS) infection induces the production of Abs that cross-react with host neuronal proteins, and these anti-GAS mimetic Abs are associated with autoimmune diseases of the CNS. However, the mechanisms that allow these Abs to cross the blood-brain barrier (BBB) and induce neuropathology remain unresolved. We have previously shown that GAS infection in mouse models induces a robust Th17 response in nasal-associated lymphoid tissue (NALT). Here, we identified GAS-specific Th17 cells in tonsils of humans naturally exposed to GAS, prompting us to explore whether GAS-specific CD4+ T cells home to mouse brains following i.n. infection. Intranasal challenge of repeatedly GAS-inoculated mice promoted migration of GAS-specific Th17 cells from NALT into the brain, BBB breakdown, serum IgG deposition, microglial activation, and loss of excitatory synaptic proteins under conditions in which no viable bacteria were detected in CNS tissue. CD4+ T cells were predominantly located in the olfactory bulb (OB) and in other brain regions that receive direct input from the OB. Together, these findings provide insight into the immunopathology of neuropsychiatric complications that are associated with GAS infections and suggest that crosstalk between the CNS and cellular immunity may be a general mechanism by which infectious agents exacerbate symptoms associated with other CNS autoimmune disorders.
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35
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Pozzi M, Pisano S, Bertella S, Lombardi P, Pellegrino P, Molteni M, Clementi E, Bravaccio C, Radice S. On the Possible Relationship Between Anti-Streptolysin-O Titer and Neuropsychiatric Disorders Other than PANS. J Child Adolesc Psychopharmacol 2015; 25:452-3. [PMID: 26091201 DOI: 10.1089/cap.2014.0170] [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: 11/12/2022]
Affiliation(s)
- Marco Pozzi
- 1 Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Eugenio Medea , Lecco, Italy
| | - Simone Pisano
- 2 Department of Medicine and Public Health, Second University of Naples , Naples, Italy
| | - Silvana Bertella
- 1 Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Eugenio Medea , Lecco, Italy
| | - Paola Lombardi
- 2 Department of Medicine and Public Health, Second University of Naples , Naples, Italy
| | - Paolo Pellegrino
- 3 Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano , Milan, Italy
| | - Massimo Molteni
- 1 Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Eugenio Medea , Lecco, Italy
| | - Emilio Clementi
- 1 Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Eugenio Medea , Lecco, Italy .,4 Unit of Clinical Pharmacology, National Research Council (CNR) Institute of Neuroscience, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano , Milan, Italy
| | - Carmela Bravaccio
- 5 Department of Translational Medical Sciences, University Federico II of Naples , Naples, Italy
| | - Sonia Radice
- 3 Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano , Milan, Italy
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36
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Nadeau JM, Jordan C, Selles RR, Wu MS, King MA, Patel PD, Hanks CE, Arnold EB, Lewin AB, Murphy TK, Storch EA. A pilot trial of cognitive-behavioral therapy augmentation of antibiotic treatment in youth with pediatric acute-onset neuropsychiatric syndrome-related obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2015; 25:337-43. [PMID: 25978743 PMCID: PMC4442557 DOI: 10.1089/cap.2014.0149] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study reports an open trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD) exhibiting an onset pattern consistent with pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS Eleven primarily Caucasian youth with PANS-related OCD (range=4-14 years; 6 boys) who were incomplete responders to antibiotic treatment, received family-based CBT delivered either face-to-face or via web camera. RESULTS All participants completing treatment (8 of 8) were considered improved at posttreatment, and average obsessive-compulsive symptom severity was reduced by 49%. Significant reductions in obsessive-compulsive symptom severity and in clinician- and parent-rated OCD-related impairment were noted. Reductions in parent- and child-rated anxiety, child-rated OCD-related impairment, and comorbid neuropsychiatric symptoms were not statistically significant. CONCLUSIONS Gains were maintained at follow-up, with 100% (6 of 6) of those assessed remaining improved. Implications for treatment and further research are discussed.
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Affiliation(s)
- Joshua M. Nadeau
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Rogers Behavioral Health, Tampa Bay, Florida
| | - Cary Jordan
- Department of Disability and Psychoeducational Studies, University of Arizona, Tucson, Arizona
| | - Robert R. Selles
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychology, University of South Florida, Tampa, Florida
| | - Monica S. Wu
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychology, University of South Florida, Tampa, Florida
| | - Morgan A. King
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Priyal D. Patel
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Camille E. Hanks
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Elysse B. Arnold
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychology, University of South Florida, Tampa, Florida
| | - Adam B. Lewin
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychiatry and Neuroscience, University of South Florida, St. Petersburg, Florida
| | - Tanya K. Murphy
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychiatry and Neuroscience, University of South Florida, St. Petersburg, Florida.,All Children's Hospital – Johns Hopkins Medicine, Baltimore, Maryland
| | - Eric A. Storch
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Rogers Behavioral Health, Tampa Bay, Florida.,Department of Psychology, University of South Florida, Tampa, Florida.,Department of Psychiatry and Neuroscience, University of South Florida, St. Petersburg, Florida.,All Children's Hospital – Johns Hopkins Medicine, Baltimore, Maryland
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37
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Gerardi DM, Casadonte J, Patel P, Murphy TK. PANDAS and comorbid Kleine-Levin syndrome. J Child Adolesc Psychopharmacol 2015; 25:93-8. [PMID: 25329605 PMCID: PMC4340647 DOI: 10.1089/cap.2014.0064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Diana M. Gerardi
- Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Joseph Casadonte
- Pediatric Neurology Associates, St. Petersburg, Florida.,Department of Neurology, All Children's Hospital, St. Petersburg, Florida
| | - Priyal Patel
- Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Tanya K. Murphy
- Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychiatry, University of South Florida, Tampa, Florida
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Frankovich J, Thienemann M, Pearlstein J, Crable A, Brown K, Chang K. Multidisciplinary clinic dedicated to treating youth with pediatric acute-onset neuropsychiatric syndrome: presenting characteristics of the first 47 consecutive patients. J Child Adolesc Psychopharmacol 2015; 25:38-47. [PMID: 25695943 PMCID: PMC4340335 DOI: 10.1089/cap.2014.0081] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Abrupt, dramatic onset obsessive-compulsive disorder (OCD) and/or eating restriction with at least two coinciding symptoms (anxiety, mood dysregulation, irritability/aggression/oppositionality, behavioral regression, cognitive deterioration, sensory or motor abnormalities, or somatic symptoms) defines pediatric acute-onset neuropsychiatric syndrome (PANS). Descriptions of clinical data in such youth are limited. METHODS We reviewed charts of 53 consecutive patients evaluated in our PANS Clinic; 47 met PANS symptom criteria but not all met the requirement for "acute onset." Patients meeting full criteria for PANS were compared with patients who had a subacute/insidious onset of symptoms. RESULTS Nineteen of 47 (40%) patients in the study had acute onset of symptoms. In these patients, autoimmune/inflammatory diseases and psychiatric disorders were common in first-degree family members (71% and 78%, respectively). Most acute-onset patients had a relapsing/remitting course (84%), prominent sleep disturbances (84%), urinary issues (58%), sensory amplification (66%), gastrointestinal symptoms (42%), and generalized pain (68%). Inflammatory back pain (21%) and other arthritis conditions (28%) were also common. Suicidal and homicidal thoughts and gestures were common (44% and 17%, respectively) as were violent outbursts (61%). Group A streptococcus (GAS) was the most commonly identified infection at onset (21%) and during flares (74%). Rates of the above-mentioned characteristics did not differ between the acute-onset group and the subacute/insidious-onset groups. Low levels of immunoglobulins were more common in the subacute/insidious-onset group (75%) compared with the acute-onset group (22%), but this was not statistically significant (p=0.06). CONCLUSIONS In our PANS clinic, 40% of patients had acute onset of symptoms. However, those with and without acute onset of symptoms had similar symptom presentation, rates of inflammatory conditions, somatic symptoms, and violent thoughts and behaviors. GAS infections were the most commonly identified infection at onset and at symptom flares. Because of the wide variety of medical and psychiatric symptoms, youth with PANS may require a multidisciplinary team for adequate care management.
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Affiliation(s)
- Jennifer Frankovich
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Pearlstein
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Amber Crable
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kayla Brown
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kiki Chang
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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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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