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Dore S, Satta D, Zinellu A, Boscia G, Carta A, Fruschelli M, Serra R, Pinna A. Ocular Tics and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Diseases 2024; 12:83. [PMID: 38785738 PMCID: PMC11120000 DOI: 10.3390/diseases12050083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/13/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
Little is known about ocular tics in Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections (PANDAS). In this retrospective study, we examined the clinical records of children with motor tics referred to the Ophthalmology Unit, Azienda Ospedaliero-Universitaria di Sassari, Italy, in 2010-2019. The presence of ocular tics was investigated. Data about antistreptolysin O (ASO) and anti-DNase B antibody titers, erythrocyte sedimentation rate (ESR), plasma C-reactive protein (CRP), and antibiotic use were recorded. Forty children (thirty-four boys and six girls; mean age: 7.65 ± 2.5 years) with motor tics were identified; thirty-three (82.5%) showed ocular tics. Children with ocular tics had significantly higher titers of anti-DNase B antibodies (p = 0.04) and CRP (p = 0.016) than those with extraocular tics. A diagnosis of PANDAS was made in 24 (60%) children. PANDAS children with oculomotor tics had significantly higher titers of anti-DNase B antibodies (p = 0.05) than those with extraocular tics. Oral antibiotics were given to 25/33 (76%) children with ocular tics and 21/24 (87.5%) with PANDAS. All treated patients showed marked improvement/complete resolution of symptoms. Results suggest that higher titers of anti-DNase B antibodies may be implicated in the pathogenesis of ocular tics in PANDAS. Oral antibiotics may be beneficial in improving ocular tics. Further research is necessary to confirm our findings.
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Affiliation(s)
- Stefano Dore
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
- Ophthalmology Unit, Azienda Ospedaliero Universitaria di Sassari, 07100 Sassari, Italy
| | - Daniele Satta
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Giacomo Boscia
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy;
| | - Arturo Carta
- Ophthalmology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Mario Fruschelli
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy;
| | - Rita Serra
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
| | - Antonio Pinna
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
- Ophthalmology Unit, Azienda Ospedaliero Universitaria di Sassari, 07100 Sassari, Italy
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Trau SP, Singer HS. Tourette Syndrome and Tic Disorders. Pediatr Rev 2024; 45:85-95. [PMID: 38296781 DOI: 10.1542/pir.2023-006014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Steven P Trau
- Division of Child Neurology, Department of Neurology, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, NC
| | - Harvey S Singer
- Department of Neurology, Johns Hopkins Hospital and the Kennedy Krieger Institute, Baltimore, MD
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3
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Thorsson M, Galazka MA, Hajjari P, Fernell E, Delafield-Butt J, Gillberg C, Johnson M, Åsberg Johnels J, Hadjikhani N. A novel tablet-based motor coordination test performs on par with the Beery VMI subtest and offers superior temporal metrics: findings from children with pediatric acute-onset neuropsychiatric syndrome. Exp Brain Res 2023; 241:1421-1436. [PMID: 37052647 PMCID: PMC10130113 DOI: 10.1007/s00221-023-06612-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Abstract
Neuropsychiatric and neurodevelopmental disorders are often associated with coordination problems. Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) constitutes a specific example of acute and complex symptomatology that includes difficulties with motor control. The present proof-of-concept study aimed at testing a new, bespoke tablet-based motor coordination test named SpaceSwipe, providing fine-grained measures that could be used to follow-up on symptoms evolution in PANS. This test enables computationally precise and objective metrics of motor coordination, taking into account both directional and spatial features continuously. We used SpaceSwipe to assess motor coordination in a group of children with PANS (n = 12, assessed on in total of 40 occasions) and compared it against the motor coordination subtest from the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) 6th edition, traditionally used to follow-up symptomatology. Using a bivariate linear regression, we found that 33 s of the directional offset from tracking a moving target in SpaceSwipe could predict the Beery VMI motor coordination (VMI MC) raw scores (mean absolute error: 1.75 points). Positive correlations between the predicted scores and the VMI MC scores were found for initial testing (radj = 0.87) and for repeated testing (radj = 0.79). With its short administration time and its close prediction to Beery VMI scores, this proof-of-concept study demonstrates the potential for SpaceSwipe as a patient-friendly tool for precise, objective assessment of motor coordination in children with neurodevelopmental or neuropsychiatric disorders.
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Affiliation(s)
- Max Thorsson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden.
- , Gothenburg, Sweden.
| | - Martyna A Galazka
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Parisa Hajjari
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Elisabeth Fernell
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Mats Johnson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Jakob Åsberg Johnels
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Section of Speech and Language Pathology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Nouchine Hadjikhani
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
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4
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Vreeland A, Thienemann M, Cunningham M, Muscal E, Pittenger C, Frankovich J. Neuroinflammation in Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, and Pediatric Acute Onset Neuropsychiatric Syndrome. Psychiatr Clin North Am 2023; 46:69-88. [PMID: 36740356 DOI: 10.1016/j.psc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sydenham chorea (SC), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are postinfectious neuroinflammatory diseases that involve the basal ganglia and have obsessive-compulsive disorder as a major manifestation. As is true for many childhood rheumatological diseases and neuroinflammatory diseases, SC, PANDAS and PANS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. Research on the treatment of these disorders depend on three complementary modes of intervention including: treating the symptoms, treating the source of inflammation, and treating disturbances of the immune system. Future studies should aim to integrate neuroimaging, inflammation, immunogenetic, and clinical data (noting the stage in the clinical course) to increase our understanding and treatment of SC, PANDAS, PANS, and all other postinfectious/immune-mediated behavioral disorders.
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Affiliation(s)
- Allison Vreeland
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA; Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA.
| | - Margo Thienemann
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA; Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA
| | - Madeleine Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Eyal Muscal
- Department of Rheumatology, Texas Children's Hospital, Houston, TX, USA
| | | | - Jennifer Frankovich
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA; Division of Pediatrics, Department of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
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5
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Marazziti D, Palermo S, Arone A, Massa L, Parra E, Simoncini M, Martucci L, Beatino MF, Pozza A. Obsessive-Compulsive Disorder, PANDAS, and Tourette Syndrome: Immuno-inflammatory Disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1411:275-300. [PMID: 36949315 DOI: 10.1007/978-981-19-7376-5_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
In the last years, much focus has been given to the possible role of inflammatory and immunologic alterations in the pathophysiology of obsessive-compulsive disorder (OCD) and some related conditions, such as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) and Tourette syndrome (TS). Although the matter is intriguing, the available data are still controversial and/or limited. Therefore, the aim of this chapter was at reviewing and commenting on the literature on possible dysfunctions of inflammatory and immune system processes in OCD, PANDAS, and TS.This narrative review was carried out through searching PubMed and Google Scholar for English language papers from January 1985 to December 31, 2021.The data gathered up to now would suggest that the mechanisms involved might be heterogeneous according to the age of the patients and the disorder examined. Indeed, PANDAS seem more related to infections triggering autoimmunity not necessarily following group A beta-hemolytic streptococcal (GABHS) infection, as supposed in the past. Autoimmunity seems also important in TS, if coupled with an individual vulnerability that can be genetic and/or environmental. The data in adult OCD, albeit scattered and sometimes obtained in small samples of patients, would indicate that immune system and inflammatory processes are involved in the pathophysiology of the disorder. However, it is still unclear to conclude whether they are primary or secondary phenomena.In conclusion, taken together, the current findings pave that way towards novel and promising domains to explore the pathophysiology of OCD and related disorders, as well towards the development of innovative therapeutic strategy beyond current pharmacological paradigms.
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Affiliation(s)
- Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy.
- Saint Camillus International University of Health and Medical Sciences - UniCamillus, Rome, Italy.
| | - Stefania Palermo
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Alessandro Arone
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Lucia Massa
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Elisabetta Parra
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Marly Simoncini
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Lucia Martucci
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Maria Francesca Beatino
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Andrea Pozza
- Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze, University of Siena, Siena, Italy
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Blum K, Dennen CA, Braverman ER, Gupta A, Baron D, Downs BW, Bagchi D, Thanos P, Pollock M, Khalsa J, Elman I, Bowirrat A, Badgaiyan RA. Hypothesizing That Pediatric Autoimmune Neuropsychiatric Associated Streptococcal (PANDAS) Causes Rapid Onset of Reward Deficiency Syndrome (RDS) Behaviors and May Require Induction of "Dopamine Homeostasis". OPEN JOURNAL OF IMMUNOLOGY 2022; 12:65-75. [PMID: 36407790 PMCID: PMC9670240 DOI: 10.4236/oji.2022.123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with group A streptococcal infections (PANDAS) is a concept that is used to characterize a subset of children with neuropsychiatric symptoms, tic disorders, or obsessive-compulsive disorder (OCD), whose symptoms are exacerbated by group A streptococcal (GAS) infection. PANDAS has been known to cause a sudden onset of reward deficiency syndrome (RDS). RDS includes multiple disorders that are characterized by dopaminergic signaling dysfunction in the brain reward cascade (BRC), which may result in addiction, depression, avoidant behaviors, anxiety, tic disorders, and/or OCD. According to research by Blum et al., the dopamine receptor D2 (DRD2) gene polymorphisms are important prevalent genetic determinants of RDS. The literature demonstrates that infections like Borrelia and Lyme, as well as other infections like group A beta-hemolytic streptococcal (GABHS), can cause an autoimmune reaction and associated antibodies target dopaminergic loci in the mesolimbic region of the brain, which interferes with brain function and potentially causes RDS-like symptoms/behaviors. The treatment of PANDAS remains controversial, especially since there have been limited efficacy studies to date. We propose an innovative potential treatment for PANDAS based on previous clinical trials using a pro-dopamine regulator known as KB220 variants. Our ongoing research suggests that achieving "dopamine homeostasis" by precision-guided DNA testing and pro-dopamine modulation could result in improved therapeutic outcomes.
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Affiliation(s)
- Kenneth Blum
- Center for Mental Health and Sports, Psychiatry, Western University Health Sciences, Pomona, USA
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, USA
- Department Psychiatry, Boonshoff School of Medicine, Wright University, Dayton, USA
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
- Department of Psychiatry, School of Medicine, University of Vermont, Burlington, USA
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health Northeast, Philadelphia, USA
| | | | | | - David Baron
- Center for Mental Health and Sports, Psychiatry, Western University Health Sciences, Pomona, USA
| | - Bernard William Downs
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
| | - Debasis Bagchi
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
- Department of Pharmaceutical Sciences, Texas Southern University, Houston, USA
| | - Panayotis Thanos
- Department of Psychology & Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions (BNNLA), Research Institute on Addictions, University at Buffalo, Buffalo, USA
| | - Maureen Pollock
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, USA
| | - Jag Khalsa
- Department of Microbiology, Immunology, and Tropical Medicine, School of Medicine, George Washington University, Washington DC, USA
| | - Igor Elman
- Cambridge Health Alliance, Harvard Medical School, Cambridge, USA
| | - Abdalla Bowirrat
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Rajendra A. Badgaiyan
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, USA
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Health Science Center, San Antonio, USA
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Pfeiffer HCV, Wickstrom R, Skov L, Sørensen CB, Sandvig I, Gjone IH, Ygberg S, Visscher C, Idring Nordstrom S, Herner LB, Hesselmark E, Hedderly T, Lim M, Debes NM. Clinical guidance for diagnosis and management of suspected Pediatric Acute-onset Neuropsychiatric Syndrome in the Nordic countries. Acta Paediatr 2021; 110:3153-3160. [PMID: 33848371 DOI: 10.1111/apa.15875] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/16/2021] [Accepted: 03/19/2021] [Indexed: 12/13/2022]
Abstract
Pediatric acute-onset neuropsychiatric syndrome is a clinical concept used to describe a subgroup of children with sudden onset of psychiatric and somatic symptoms. The diagnostic term and especially management of children differs depending on the clinical setting to which they present, and the diagnosis and management is controversial. The aim of this paper is to propose a clinical guidance including homogenous diagnostic work-up and management of paediatric acute onset neuropsychiatric syndrome within the Nordic countries. The guidance is authored by a Nordic-UK working group consisting of paediatric neurologist, child psychiatrists and psychologists from Denmark, Norway, Sweden and Great Britain, and is the result of broad consensus. CONCLUSION: Consensus was achieved in the collaboration on work-up and treatment of patients with paediatric acute-onset neuropsychiatric syndrome, which we hope will improve and homogenise patient care and enable future collaborative research in the field.
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Affiliation(s)
- Helle Cecilie Viekilde Pfeiffer
- Department of Child Neurology Oslo University Hospital Oslo Norway
- Department of Pediatrics and Adolescence Medicine Copenhagen University Hospital Hvidovre Copenhagen Denmark
| | - Ronny Wickstrom
- Department of Women´s and Children's Health Neuropediatric Unit Karolinska Institutet Stockholm Sweden
| | - Liselotte Skov
- Department of Pediatrics and Adolescence Medicin Copenhagen University Hospital Herlev Copenhagen Denmark
| | - Camilla Birgitte Sørensen
- Department of Pediatrics and Adolescence Medicin Copenhagen University Hospital Herlev Copenhagen Denmark
| | - Inger Sandvig
- Department of Child Neurology Oslo University Hospital Oslo Norway
| | - Inger Helene Gjone
- Division of Pediatric and Adolescent Medicine Department of Child and Adolescent Mental Health in Hospitals Oslo University Hospital Oslo Norway
| | - Sofia Ygberg
- Department of Women´s and Children's Health Neuropediatric Unit Karolinska Institutet Stockholm Sweden
| | - Caroline Visscher
- Centre for Psychiatry Research Department of Clinical Neuroscience Region Stockholm, Child and Adolescent Psychiatry Research Center Karolinska Institutet & Stockholm Healthcare Services Stockholm Sweden
| | - Selma Idring Nordstrom
- Centre for Psychiatry Research Department of Clinical Neuroscience Region Stockholm, Child and Adolescent Psychiatry Research Center Karolinska Institutet & Stockholm Healthcare Services Stockholm Sweden
| | - Linn Breen Herner
- Division of Pediatric and Adolescent Medicine Department of Child and Adolescent Mental Health in Hospitals Oslo University Hospital Oslo Norway
| | - Eva Hesselmark
- Centre for Psychiatry Research Department of Clinical Neuroscience Region Stockholm, Child and Adolescent Psychiatry Research Center Karolinska Institutet & Stockholm Healthcare Services Stockholm Sweden
| | - Tammy Hedderly
- Tic and Neurodevelopmental Movements Service (TANDeM) Children's Neurosciences Centre Evelina London Children's Hospital, Guys and St Thomas NHS Foundation Trust London UK
| | - Ming Lim
- Children's Neurosciences Evelina London Children's Hospital at Guy's and St Thomas’ NHS Foundation Trust King's Health Partners Academic Health Science Centre London UK
| | - Nanette Marinette Debes
- Department of Pediatrics and Adolescence Medicin Copenhagen University Hospital Herlev Copenhagen Denmark
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Rea I, Guido CA, Spalice A. Clinical Features in Patients With PANDAS/PANS and Therapeutic Approaches: A Retrospective Study. Front Neurol 2021; 12:741176. [PMID: 34650513 PMCID: PMC8505529 DOI: 10.3389/fneur.2021.741176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The clinical characteristics of patients with PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) and PANS (pediatric acute-onset neuropsychiatric syndrome) and the efficacy of antibiotic therapy with psychotherapy and antipsychotics were investigated to improve neurological symptoms as well as obsessive compulsive disorder (OCD). Methods: We retrospectively analyzed 62 patients with a clinical diagnosis of PANDAS/PANS enrolled from May 14, 2013 to September 15, 2020 in the Neurology Childhood Division, Department of Pediatrics at Sapienza, Rome. Clinical manifestations, neurological and psychiatric, laboratory investigations, and familiar history were collected to evaluate the differences between the two groups. The effects of various therapeutic approaches were examined. Descriptive and comparative statistical analyses were performed. Results: The mean age at onset of PANDAS/PANS symptoms was 6.2 ± 1.2 years. The most common diagnosis was PANDAS, followed by PANS. Neurological and psychiatric symptoms were mostly evident in both groups (>70% of the population), with no significant difference between them (P = 0.52 and P = 0.15, respectively). Irritability, aggressivity, and food restriction were more prevalent in children with PANS than in those with PANDAS (P = 0.024 and P = 0.0023, respectively). The levels of anti-streptolysin O and anti-DNAse B 10-fold higher in PANDAS than those in PANS (P < 0.0001). Antibiotics or psychotherapy were administered in most cases (90.3 and 53.2%, respectively), followed by antipsychotic treatments (24.2%). In the multivariate analysis, among the therapies used, psychotherapy significantly resulted in the most efficacious relief of OCD, reducing stress in patients and their parents (P = 0.042). Conclusion: Our findings confirm a clear clinical difference between the two groups, PANDAS and PANS, using different approaches. In fact, irritability, aggressivity, and food restriction were significantly more frequent in children with PANS and the levels of anti-streptolysin O and anti-DNAse B were higher in PANDAS. Another relevant finding is the efficacy of psychotherapy, especially for obsessive-compulsive disorder, and of antibiotic prophylaxis in managing acute neurological symptoms.
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Affiliation(s)
- Isabella Rea
- Child Neurology Division, Department of Pediatrics, “Sapienza” University of Rome, Rome, Italy
| | | | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, “Sapienza” University of Rome, Rome, Italy
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Rafeek RAM, Lobbe CM, Wilkinson EC, Hamlin AS, Andronicos NM, McMillan DJ, Sriprakash KS, Ketheesan N. Group A streptococcal antigen exposed rat model to investigate neurobehavioral and cardiac complications associated with post-streptococcal autoimmune sequelae. Animal Model Exp Med 2021; 4:151-161. [PMID: 34179722 PMCID: PMC8212825 DOI: 10.1002/ame2.12164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/03/2021] [Indexed: 12/25/2022] Open
Abstract
Background The neuropsychiatric disorders due to post-streptococcal autoimmune complications such as Sydenham's chorea (SC) are associated with acute rheumatic fever and rheumatic heart disease (ARF/RHD). An animal model that exhibits characteristics of both cardiac and neurobehavioral defects in ARF/RHD would be an important adjunct for future studies. Since age, gender, strain differences, and genotypes impact on the development of autoimmunity, we investigated the behavior of male and female Wistar and Lewis rat strains in two age cohorts (<6 weeks and >12 weeks) under normal husbandry conditions and following exposure to group A streptococcus (GAS). Methods Standard behavioral assessments were performed to determine the impairments in fine motor control (food manipulation test), gait and balance (beam walking test), and obsessive-compulsive behavior (grooming and marble burying tests). Furthermore, electrocardiography, histology, and behavioral assessments were performed on male and female Lewis rats injected with GAS antigens. Results For control Lewis rats there were no significant age and gender dependent differences in marble burying, food manipulation, beam walking and grooming behaviors. In contrast significant age-dependent differences were observed in Wistar rats in all the behavioral tests except for food manipulation. Therefore, Lewis rats were selected for further experiments to determine the effect of GAS. After exposure to GAS, Lewis rats demonstrated neurobehavioral abnormalities and cardiac pathology akin to SC and ARF/RHD, respectively. Conclusion We have characterised a new model that provides longitudinal stability of age-dependent behavior, to simultaneously investigate both neurobehavioral and cardiac abnormalities associated with post-streptococcal complications.
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Affiliation(s)
| | - Catherine M. Lobbe
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
| | - Ethan C. Wilkinson
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
| | - Adam S. Hamlin
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
| | | | - David J. McMillan
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
- School of Science, Technology, Engineering and Genecology Research CentreUniversity of the Sunshine CoastMaroochydore DCQLDAustralia
| | - Kadaba S. Sriprakash
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
- QIMR Berghofer Medical Research InstituteHerstonQLDAustralia
| | - Natkunam Ketheesan
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
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10
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Troyer EA, Kohn JN, Ecklu-Mensah G, Aleti G, Rosenberg DR, Hong S. Searching for host immune-microbiome mechanisms in obsessive-compulsive disorder: A narrative literature review and future directions. Neurosci Biobehav Rev 2021; 125:517-534. [PMID: 33639178 DOI: 10.1016/j.neubiorev.2021.02.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 02/09/2021] [Accepted: 02/22/2021] [Indexed: 12/20/2022]
Abstract
Obsessive-compulsive disorder (OCD) is disabling and often treatment-refractory. Host immunity and gut microbiota have bidirectional communication with each other and with the brain. Perturbations to this axis have been implicated in neuropsychiatric disorders, but immune-microbiome signaling in OCD is relatively underexplored. We review support for further pursuing such investigations in OCD, including: 1) gut microbiota has been associated with OCD, but causal pathogenic mechanisms remain unclear; 2) early environmental risk factors for OCD overlap with critical periods of immune-microbiome development; 3) OCD is associated with increased risk of immune-mediated disorders and changes in immune parameters, which are separately associated with the microbiome; and 4) gut microbiome manipulations in animal models are associated with changes in immunity and some obsessive-compulsive symptoms. Theoretical pathogenic mechanisms could include microbiota programming of cytokine production, promotion of expansion and trafficking of peripheral immune cells to the CNS, and regulation of microglial function. Immune-microbiome signaling in OCD requires further exploration, and may offer novel insights into pathogenic mechanisms and potential treatment targets for this disabling disorder.
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Affiliation(s)
- Emily A Troyer
- Department of Psychiatry, University of California San Diego, La Jolla, California, United States.
| | - Jordan N Kohn
- Department of Psychiatry, University of California San Diego, La Jolla, California, United States
| | - Gertrude Ecklu-Mensah
- Department of Medicine and Scripps Institution of Oceanography, University of California San Diego, La Jolla, California, United States
| | - Gajender Aleti
- Department of Psychiatry, University of California San Diego, La Jolla, California, United States
| | - David R Rosenberg
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, Michigan, United States
| | - Suzi Hong
- Department of Psychiatry, University of California San Diego, La Jolla, California, United States; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, United States
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11
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Dop D, Marcu IR, Padureanu R, Niculescu CE, Padureanu V. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (Review). Exp Ther Med 2021; 21:94. [PMID: 33363605 PMCID: PMC7725005 DOI: 10.3892/etm.2020.9526] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/26/2020] [Indexed: 12/04/2022] Open
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinically characterized by the sudden onset of obsessive-compulsive manifestations, motor and verbal tics, as well as other behavioral symptoms in a group of children with B-hemolytic streptococcal infection. PANDAS are considered autoimmune diseases because the streptococcal infection and response can be demonstrated. The most frequent physiopathological mechanism is molecular mimicry: A foreign antigen shares sequence or structural similarities with self-antigens. A thorough review of the literature was carried out using the PubMed database and SCOPUS, searching for immunological, clinical and microbiological aspects, as well as the treatment of the PANDAS syndrome. The diagnosis is clinical and it requires a careful medical history and a thorough physical examination, while the treatment is complex. Untreated or unrecognized manifestations of PANDAS can increase the risk of obsessive-compulsive manifestations and tics during adulthood. Taking this into consideration, further studies are required to establish the best method of therapy.
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Affiliation(s)
- Dalia Dop
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Iulia Rahela Marcu
- Department of Physical and Rehabilitation Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Rodica Padureanu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Carmen Elena Niculescu
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
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12
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Martino D, Johnson I, Leckman JF. What Does Immunology Have to Do With Normal Brain Development and the Pathophysiology Underlying Tourette Syndrome and Related Neuropsychiatric Disorders? Front Neurol 2020; 11:567407. [PMID: 33041996 PMCID: PMC7525089 DOI: 10.3389/fneur.2020.567407] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022] Open
Abstract
Objective: The goal of this article is to review the past decade's literature and provide a critical commentary on the involvement of immunological mechanisms in normal brain development, as well as its role in the pathophysiology of Tourette syndrome, other Chronic tic disorders (CTD), and related neuropsychiatric disorders including Obsessive-compulsive disorder (OCD) and Attention deficit hyperactivity disorder (ADHD). Methods: We conducted a literature search using the Medline/PubMed and EMBASE electronic databases to locate relevant articles and abstracts published between 2009 and 2020, using a comprehensive list of search terms related to immune mechanisms and the diseases of interest, including both clinical and animal model studies. Results: The cellular and molecular processes that constitute our "immune system" are crucial to normal brain development and the formation and maintenance of neural circuits. It is also increasingly evident that innate and adaptive systemic immune pathways, as well as neuroinflammatory mechanisms, play an important role in the pathobiology of at least a subset of individuals with Tourette syndrome and related neuropsychiatric disorders In the conceptual framework of the holobiont theory, emerging evidence points also to the importance of the "microbiota-gut-brain axis" in the pathobiology of these neurodevelopmental disorders. Conclusions: Neural development is an enormously complex and dynamic process. Immunological pathways are implicated in several early neurodevelopmental processes including the formation and refinement of neural circuits. Hyper-reactivity of systemic immune pathways and neuroinflammation may contribute to the natural fluctuations of the core behavioral features of CTD, OCD, and ADHD. There is still limited knowledge of the efficacy of direct and indirect (i.e., through environmental modifications) immune-modulatory interventions in the treatment of these disorders. Future research also needs to focus on the key molecular pathways through which dysbiosis of different tissue microbiota influence neuroimmune interactions in these disorders, and how microbiota modification could modify their natural history. It is also possible that valid biomarkers will emerge that will guide a more personalized approach to the treatment of these disorders.
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Affiliation(s)
- Davide Martino
- Department of Clinical Neurosciences & Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Isaac Johnson
- Child Study Center, Yale University, New Haven, CT, United States
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - James F. Leckman
- Child Study Center, Yale University, New Haven, CT, United States
- Departments of Psychiatry, Pediatrics and Psychology, Yale University, New Haven, CT, United States
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13
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Baj J, Sitarz E, Forma A, Wróblewska K, Karakuła-Juchnowicz H. Alterations in the Nervous System and Gut Microbiota after β-Hemolytic Streptococcus Group A Infection-Characteristics and Diagnostic Criteria of PANDAS Recognition. Int J Mol Sci 2020; 21:E1476. [PMID: 32098238 PMCID: PMC7073132 DOI: 10.3390/ijms21041476] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
The objective of this paper is to review and summarize conclusions from the available literature regarding Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). The authors have independently reviewed articles from 1977 onwards, primarily focusing on the etiopathology, symptoms, differentiation between similar psychiatric conditions, immunological reactions, alterations in the nervous system and gut microbiota, genetics, and the available treatment for PANDAS. Recent research indicates that PANDAS patients show noticeable alterations within the structures of the central nervous system, including caudate, putamen, globus pallidus, and striatum, as well as bilateral and lentiform nuclei. Likewise, the presence of autoantibodies that interact with basal ganglia was observed in PANDAS patients. Several studies also suggest a relationship between the presence of obsessive-compulsive disorders like PANDAS and alterations to the gut microbiota. Further, genetic predispositions-including variations in the MBL gene and TNF-α-seem to be relevant regarding PANDAS syndrome. Even though the literature is still scarce, the authors have attempted to provide a thorough insight into the PANDAS syndrome, bearing in mind the diagnostic difficulties of this condition.
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Affiliation(s)
- Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-090 Lublin, Poland
| | - Elżbieta Sitarz
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (E.S.); (A.F.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (E.S.); (A.F.)
| | - Katarzyna Wróblewska
- North London Forensic Service, Chase Farm Hospital, 127 The Ridgeway, Enfield, Middlesex EN2 8JL, UK;
| | - Hanna Karakuła-Juchnowicz
- Chair and 1st Department of Psychiatry, Psychotherapy and Early Intervention, Medical University of Lublin, Gluska Street 1, 20-439 Lublin, Poland;
- Department of Clinical Neuropsychiatry, Medical University of Lublin, Gluska Street 1, 20-439 Lublin, Poland
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Abstract
This review and commentary is the product of an invited lecture called "Autoimmunity: PANS/PANDAS" presented at the 2018 Neurobiology of Diseases in Children Symposium in Chicago, IL. The talk addressed clinical and scientific questions and recently published data. At this time, among highly experienced and respected clinicians and researchers spanning relevant disciplines, there is substantial controversy regarding a role for inflammation in producing tics and obsessive-compulsive disorder. This commentary summarizes these controversies, discusses reasons for opposing views on best clinical practices, and concludes with suggestions for pathways forward.
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Affiliation(s)
- Donald L. Gilbert
- Division of Neurology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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15
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Gerentes M, Pelissolo A, Rajagopal K, Tamouza R, Hamdani N. Obsessive-Compulsive Disorder: Autoimmunity and Neuroinflammation. Curr Psychiatry Rep 2019; 21:78. [PMID: 31367805 DOI: 10.1007/s11920-019-1062-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Here, we propose to review the immuno-inflammatory hypothesis in OCD given the concurrent incidence of autoimmune comorbidities, infectious stigma, and raised levels of inflammatory markers in a significant subset of patients. A better understanding of the immune dysfunction in OCD may allow stratifying the patients in order to design personalized pharmaco/psychotherapeutic strategies. RECENT FINDINGS A persistent low-grade inflammation involving both innate and adaptive immune system with coexisting autoimmune morbidities and stigma of infectious events has been prominently observed in OCD. Hence, specific treatments targeting inflammation/infection are a feasible alternative in OCD. This review highlights that OCD is associated with low-grade inflammation, neural antibodies, and neuro-inflammatory and auto-immune disorders. In some subset of OCD patients, autoimmunity is likely triggered by specific bacterial, viral, or parasitic agents with overlapping surface epitopes in CNS. Hence, subset-profiling in OCD is warranted to benefit from distinct immune-targeted treatment modalities.
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Affiliation(s)
- Mona Gerentes
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Antoine Pelissolo
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.,Faculté de médecine, UPEC, Université Paris-Est, 94000, Créteil, France
| | | | - Ryad Tamouza
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Nora Hamdani
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France. .,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.
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16
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Lamothe H, Baleyte JM, Smith P, Pelissolo A, Mallet L. Individualized Immunological Data for Precise Classification of OCD Patients. Brain Sci 2018; 8:E149. [PMID: 30096863 PMCID: PMC6119917 DOI: 10.3390/brainsci8080149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Pauline Smith
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
| | - Antoine Pelissolo
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- INSERM, U955, Team 15, 94000 Créteil, France.
| | - Luc Mallet
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, 1202 Geneva, Switzerland.
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17
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Affiliation(s)
- Monika L Dietrich
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA
| | - Russell W Steele
- Department of Pediatrics, Ochsner Health Center for Children, New Orleans, LA.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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18
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A Pediatric Neurology Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute-Onset Neuropsychiatric Syndrome. J Pediatr 2018; 199:243-251. [PMID: 29793872 DOI: 10.1016/j.jpeds.2018.04.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/25/2018] [Accepted: 04/17/2018] [Indexed: 12/21/2022]
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19
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Immune system and obsessive-compulsive disorder. Psychoneuroendocrinology 2018; 93:39-44. [PMID: 29689421 DOI: 10.1016/j.psyneuen.2018.04.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recently, much attention has been devoted to the possible alterations of the immune system in obsessive-compulsive disorder (OCD). Therefore, the aim of this paper was to review the current literature on the relationships between OCD and immune system. METHODS A PubMed and Google Scholar search was performed with specific keywords. RESULTS In the childhood, much emphasis has been given to the relationship between group A Streptococcus (GAS) infection and the development of a group of clinical syndromes characterized by neuropsychiatric symptoms known as "pediatric autoimmune neuropsychiatric disorders associated with streptococcus" (PANDAS). However, more recently, PANDAS has been reconsidered and evolved towards pediatric acute-onset neuropsychiatric syndrome (PANS) and/or Childhood Acute Neuropsychiatric Syndrome (CANS) all characterized by the presence of typical of OCD symptoms and tics. In adult OCD patients, different immunological parameters have been described to differ from those of healthy control subjects, although a few numbers of studies were carred out and most of them performed in small samples. CONCLUSIONS Although the exact relationships between OCD and immune processes are still unclear, available literature supports their role in the pathophysiology of OCD, while providing a fascinating hint for possible immunotherapeutic treatments in OCD.
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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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21
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A critical review of PANDAS research in the context of obsessive compulsive disorder. HEALTH PSYCHOLOGY REPORT 2018. [DOI: 10.5114/hpr.2018.70356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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22
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Swedo SE, Frankovich J, Murphy TK. Overview of Treatment of Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2017; 27:562-565. [PMID: 28722464 PMCID: PMC5610386 DOI: 10.1089/cap.2017.0042] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Susan E. Swedo
- Section on Behavioral Pediatrics, Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - Jennifer Frankovich
- Divisions of Pediatric, Department of Allergy, Immunology, and Rheumatology, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine, Palo Alto, California
| | - Tanya K. Murphy
- Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, St. Petersburg, Florida
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23
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Calaprice D, Tona J, Parker-Athill EC, Murphy TK. A Survey of Pediatric Acute-Onset Neuropsychiatric Syndrome Characteristics and Course. J Child Adolesc Psychopharmacol 2017; 27:607-618. [PMID: 28140619 DOI: 10.1089/cap.2016.0105] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To date, studies in the area of pediatric acute-onset neuropsychiatric syndrome (PANS; including pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection [PANDAS] and pediatric infection-triggered neuropsychiatric disorder [PITAND]) have been relatively small and hence unable to comprehensively address questions of disease heterogeneity (e.g., by age, gender), comorbidities, and progression. In this study, we investigated an internet survey sample to more fully characterize the phenotypic traits; medical, family, and developmental history; functional challenges; and clinical course associated with PANS. METHODS Six hundred and ninety-eight patients with clinical diagnoses of PANS were included in this study. Participants, who included parents and legal guardians (for minors) or the PANS patients themselves (for those ages 18 and older), were asked to complete a 146-question survey designed to ascertain medical, developmental, and family history; PANS symptomatology; medical and nonmedical interventions for PANS; PANS course; PANS outcomes; and access to PANS care. RESULTS Our results agree with previous findings concerning the core symptoms of PANS as well as its male predominance (65% in this survey) and infection-triggered onset, thus validating the study population. Infection was implicated as the primary inciting factor in 65% of patients; 54% of patients reported an association with group A streptococcus specifically. The results of this survey also revealed new findings, including a surprisingly strong impact of gender and pubertal status on symptom course and chronicity, a high rate of medical comorbidity suggesting generalized immune dysfunction, a profound impact of PANS episodes on functional status, and a role for early resolution of infection through antibiotic treatment in disease course. CONCLUSIONS This study serves as the first survey of its size to provide insight into the global clinical picture and range of phenotypes of PANS patients. Significant results included the impact of gender and pubertal status on phenotype, affirmation of the role of the immune system in PANS pathology, and the role of timely resolution of infection in clinical outcomes. Understanding how PANS presents in a broad population-based sample, within the limitations of a self-selected and administered online survey, is an important step toward improving diagnosis, creating more targeted treatment options, educating the clinical and research community, and generating hypotheses for future prospective research.
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Affiliation(s)
| | - Janice Tona
- 2 Department of Rehabilitation Science, University at Buffalo , Buffalo, New York
| | | | - Tanya K Murphy
- 3 Department of Pediatrics, University of South Florida , St. Petersburg, Florida.,4 Department of Psychiatry, University of South Florida , St. Petersburg, Florida
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24
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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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25
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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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26
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Thienemann M, Murphy T, Leckman J, Shaw R, Williams K, Kapphahn C, Frankovich J, Geller D, Bernstein G, Chang K, Elia J, Swedo S. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I-Psychiatric and Behavioral Interventions. J Child Adolesc Psychopharmacol 2017; 27:566-573. [PMID: 28722481 PMCID: PMC5610394 DOI: 10.1089/cap.2016.0145] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This article outlines the consensus guidelines for symptomatic treatment for children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS). METHODS Extant literature on behavioral, psychotherapeutic, and psychopharmacologic treatments for PANS and PANDAS was reviewed. Members of the PANS Research Consortium pooled their clinical experiences to find agreement on treatment of PANS and PANDAS symptoms. RESULTS Current guidelines result from consensus among the Consortium members. CONCLUSION While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention. Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness. In general, typical evidence-based interventions are appropriate for the varied symptoms of PANS and PANDAS. Individual differences in expected response to psychotropic medication may require marked reduction of initial treatment dose. Antimicrobials and immunomodulatory therapies may be indicated, as discussed in Parts 2 and 3 of this guideline series.
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Affiliation(s)
| | - Tanya Murphy
- University of South Florida, St. Petersburg, Florida
| | | | | | - Kyle Williams
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Kiki Chang
- Stanford University, Stanford, California
| | - Josephine Elia
- Nemours, Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Susan Swedo
- National Institute of Mental Health, Bethesda, Maryland
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Williams KA, Swedo SE, Farmer CA, Grantz H, Grant PJ, D'Souza P, Hommer R, Katsovich L, King RA, Leckman JF. Randomized, Controlled Trial of Intravenous Immunoglobulin for Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections. J Am Acad Child Adolesc Psychiatry 2016; 55:860-867.e2. [PMID: 27663941 DOI: 10.1016/j.jaac.2016.06.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/15/2016] [Accepted: 07/28/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are hypothesized to occur as a result of cross-reactive antibodies produced in response to group A streptococcal infections. Previous research suggests that immunomodulatory therapies, such as intravenous immunoglobulin (IVIG), may lead to rapid and sustained symptom improvement in patients with PANDAS. METHOD A total of 35 children meeting criteria for PANDAS and moderate to severe obsessive-compulsive disorder (OCD) were enrolled in a randomized-entry, double-blind, placebo-controlled, 6-week trial of IVIG (1 g/kg/day on 2 consecutive days), followed by optional open-label treatment for nonresponders, with follow-up at 12 and 24 weeks. Primary outcome measures were the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Clinical Global Impressions-Improvement (CGI-I) rating. "Responders" were defined, a priori, by a ≥ 30% decrease in CY-BOCS total score, and a "much" or "very much" improved rating on CGI-I. RESULTS During the double-blind phase, the mean decrease in CY-BOCS score was 24% ± 31% in the IVIG group (n = 17) and 12% ± 27% in the placebo group (n = 18), with six responders in the IVIG group (35%) versus four (22%) in the placebo group; these differences were not statistically significant. Twenty-four participants met criteria for nonresponse to double-blind infusion and received open-label IVIG at week 6. Among all participants, the mean CY-BOCS improvement from baseline was 55% ± 33% at week 12 and 62% ± 33% at week 24. CONCLUSION IVIG was safe and well tolerated. Between-group differences were smaller than anticipated, and the double-blind comparison failed to demonstrate superiority of IVIG over placebo. The observed open-label improvements indicate that future trials would benefit from larger sample sizes designed in part to aid in the identification of biomarkers predictive of a positive response to immunotherapy. Future investigations focused on the natural history of PANDAS are also warranted. Clinical trial registration information-Intravenous Immunoglobulin for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections); http://clinicaltrials.gov/; NCT01281969ZIAMH002666.
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Affiliation(s)
- Kyle A Williams
- Child Study Center at Yale University School of Medicine, New Haven, CT; Pediatric Neuropsychiatry and Immunology Program at Massachusetts General Hospital, Boston, MA
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD.
| | - Cristan A Farmer
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Heidi Grantz
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - Paul J Grant
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Precilla D'Souza
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Rebecca Hommer
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Liliya Katsovich
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - Robert A King
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - James F Leckman
- Child Study Center at Yale University School of Medicine, New Haven, CT
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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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29
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McClelland M, Crombez MM, Crombez C, Wenz C, Lisius M, Mattia A, Marku S. Implications for Advanced Practice Nurses When Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS) Is Suspected: A Qualitative Study. J Pediatr Health Care 2015; 29:442-52. [PMID: 25895693 DOI: 10.1016/j.pedhc.2015.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is a relatively new but controversial diagnosis affecting hundreds of children and their families. It is generally thought to be an autoimmune disorder resulting from a streptococcal infection that causes significant and bizarre behavioral changes in children. Currently no definitive diagnostic or treatment modalities exist, which has led to misdiagnoses, ineffective treatments, and delayed care. METHODS A qualitative study was conducted that included 60 families with at least one child diagnosed with PANDAS. The purpose was to explore how families experience the disorder and what nurses can do to provide effective care. RESULTS Using paradigmatic analysis of transcribed interviews, three themes were identified: fear, frustration, and not being heard. DISCUSSION Results from this study suggest that more information is needed to better understand this challenging phenomenon from both medical and nursing perspectives. The study also reaffirms the importance of practicing the art of nursing, especially when the science is not yet established.
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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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31
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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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Toufexis MD, Hommer R, Gerardi DM, Grant P, Rothschild L, D'Souza P, Williams K, Leckman J, Swedo SE, Murphy TK. Disordered eating and food restrictions in children with PANDAS/PANS. J Child Adolesc Psychopharmacol 2015; 25:48-56. [PMID: 25329522 PMCID: PMC4340640 DOI: 10.1089/cap.2014.0063] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Sudden onset clinically significant eating restrictions are a defining feature of the clinical presentation of some of the cases of pediatric acute-onset neuropsychiatric syndrome (PANS). Restrictions in food intake are typically fueled by contamination fears; fears of choking, vomiting, or swallowing; and/or sensory issues, such as texture, taste, or olfactory concerns. However, body image distortions may also be present. We investigate the clinical presentation of PANS disordered eating and compare it with that of other eating disorders. METHODS We describe 29 patients who met diagnostic criteria for PANS. Most also exhibited evidence that the symptoms might be sequelae of infections with Group A streptococcal bacteria (the pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections [PANDAS] subgroup of PANS). RESULTS The clinical presentations are remarkable for a male predominance (2:1 M:F), young age of the affected children (mean=9 years; range 5-12 years), acuity of symptom onset, and comorbid neuropsychiatric symptoms. CONCLUSIONS The food refusal associated with PANS is compared with symptoms listed for the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) diagnosis of avoidant/restrictive food intake disorder (ARFID). Treatment implications are discussed, as well as directions for further research.
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Affiliation(s)
- Megan D. Toufexis
- Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Rebecca Hommer
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Diana M. Gerardi
- Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Paul Grant
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Leah Rothschild
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Precilla D'Souza
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Kyle Williams
- Pediatric Neuropsychiatry and Immunology Clinic, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - James Leckman
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Susan E. Swedo
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - 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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Kovacevic M, Grant P, Swedo SE. Use of intravenous immunoglobulin in the treatment of twelve youths with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. J Child Adolesc Psychopharmacol 2015; 25:65-9. [PMID: 25658609 PMCID: PMC4340809 DOI: 10.1089/cap.2014.0067] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This is a case series describing 12 youths treated with intravenous immunoglobulin (IVIG) for pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS). Although it is a clinically based series, the case reports provide new information about the short-term benefits of IVIG therapy, and are the first descriptions of long-term outcome for PANDAS patients.
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Affiliation(s)
- Miro Kovacevic
- Loyola University School of Medicine, Maywood, Illinois. Private practice, Hinsdale, Illinois
| | - Paul Grant
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Susan E. Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
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34
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Latimer ME, L'Etoile N, Seidlitz J, Swedo SE. Therapeutic plasma apheresis as a treatment for 35 severely ill children and adolescents with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. J Child Adolesc Psychopharmacol 2015; 25:70-5. [PMID: 25658452 PMCID: PMC4340509 DOI: 10.1089/cap.2014.0080] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Because of its reported similarities to Sydenham chorea, therapeutic plasma apheresis (TPA) has been proposed as a potential treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). To date, support for the use of TPA has been limited to a few anecdotal reports and a small placebo-controlled trial demonstrating dramatic symptom improvements at 1 month and 1 year follow-up. To evaluate the safety and efficacy of TPA further, we undertook a retrospective review of all PANDAS patients treated with TPA at Georgetown University Hospital between August 2009 and October 2013. METHODS Forty patients were identified, and sufficient information was available from medical records and telephone interview for 35 cases (88%). All 35 (23 boys; 12 girls) met diagnostic criteria for PANDAS (Swedo et al. 1998 ) and had severe symptoms. The TPA procedures were performed at Georgetown University Hospital using a protocol that processes a total of 4.5 blood volumes over 3-5 days (three treatments of 1.5 volumes each). Overall symptom improvements at 6 months post-TPA and long-term follow-up were estimated by parents, who also rated changes in individual symptoms to provide information about patterns of improvement. RESULTS All patients were reported to have received at least some benefit from TPA, with average improvement of 65% at 6 months post-TPA and 78% at longer-term follow-up. A decrease in the number of reported symptoms also occurred, with particular improvements in obsessive-compulsive disorder (OCD), anxiety, tics, and somatic symptoms, including dysgraphia, sleep difficulties, and urinary urgency or frequency. Contrary to expectations, preceding duration of illness was not correlated with degree of improvement following TPA, suggesting that acuity of illness is not a factor affecting response. Only two adverse events were reported: both involved reopening of the site where the central line had been placed and resolved immediately following application of pressure and re-dressing of the puncture site. CONCLUSIONS Therapeutic plasma apheresis is an invasive medical intervention that should be reserved for treatment of children and adolescents who are severely affected by PANDAS. In such patients, it appears to be a safe, well-tolerated, and beneficial treatment option.
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Affiliation(s)
- M. Elizabeth Latimer
- Pediatric Neurology Practice, Washington, DC.,Georgetown University School of Medicine, Washington, DC
| | | | - Jakob Seidlitz
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Susan E. Swedo
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
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Chang K, Koplewicz HS, Steingard R. Special issue on pediatric acute-onset neuropsychiatric syndrome. J Child Adolesc Psychopharmacol 2015; 25:1-2. [PMID: 25695940 PMCID: PMC4340339 DOI: 10.1089/cap.2015.2511] [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)
- Kiki Chang
- Stanford University School of Medicine, Stanford, California
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