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Fry R. Debate: 'Neurodiversity' - has it outrun its usefulness? Child Adolesc Ment Health 2024; 29:314-315. [PMID: 38337151 DOI: 10.1111/camh.12684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 02/12/2024]
Affiliation(s)
- Richard Fry
- Dr Fry & Associates, Winchester, UK
- The Mount Consultancy, Hampshire, UK
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2
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Leonardi L, Perna C, Bernabei I, Fiore M, Ma M, Frankovich J, Tarani L, Spalice A. Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): Immunological Features Underpinning Controversial Entities. CHILDREN (BASEL, SWITZERLAND) 2024; 11:1043. [PMID: 39334578 PMCID: PMC11430956 DOI: 10.3390/children11091043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/15/2024] [Accepted: 08/23/2024] [Indexed: 09/30/2024]
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), represent an overlapping group of disorders which is characterized by acute-onset obsessive compulsive disorders, eating restriction, tics, cognitive and behavioral deterioration which typically follows a relapsing-remitting course but some patients have a primary or secondary persistent progress. This condition is likely caused by heterogeneous inflammatory mechanisms (autoantibodies, complement activation, pro-inflammatory cytokine production) involving the basal ganglia as evidenced by imaging studies (patients vs. controls), sleep studies that found movements and/or atonia during REM sleep, and neurological soft signs that go along with basal ganglia dysfunction. The condition causes significant psychiatric and behavioral symptoms, caregiver burden and sleep abnormalities. Autoantibodies resulting from molecular mimicry of infectious agents (namely group A Streptococcus) and neuronal autoantigens that map to the basal ganglia play also a subtle role. This narrative review aims to describe the key immunological features documented thus far and that likely play a role in the pathogenesis and clinical manifestations of this disorder.
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Affiliation(s)
- Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Camilla Perna
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Irene Bernabei
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marco Fiore
- Institute of Biochemistry and Cell Biology, IBBC-CNR, 00185 Rome, Italy
| | - Meiqian Ma
- Division of Allergy, Immunology & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Jennifer Frankovich
- Division of Allergy, Immunology & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Luigi Tarani
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alberto Spalice
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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3
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Ma M, Masterson EE, Gao J, Karpel H, Chan A, Pooni R, Sandberg J, Rubesova E, Farhadian B, Willet T, Xie Y, Tran P, Silverman M, Thienemann M, Mellins E, Frankovich J. Development of Autoimmune Diseases Among Children With Pediatric Acute-Onset Neuropsychiatric Syndrome. JAMA Netw Open 2024; 7:e2421688. [PMID: 39078633 PMCID: PMC11289697 DOI: 10.1001/jamanetworkopen.2024.21688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/07/2024] [Indexed: 07/31/2024] Open
Abstract
Importance Epidemiologic studies indicate a high rate of autoimmune conditions among patients with obsessive-complusive disorder and other psychiatric conditions. Furthering the understanding of the inflammatory diatheses of psychiatric conditions may open doors to new treatment paradigms for psychiatric disorders. Objectives To evaluate whether pediatric acute-onset neuropsychiatric syndrome (PANS) is associated with an inflammatory diathesis by assessing signs of immune activation and vasculopathy during a psychiatric symptom exacerbation (flare), estimating the risk of developing arthritis and other autoimmune diseases, and characterizing subtypes of arthritis. Design, Setting, and Participants This retrospective cohort study used longitudinal clinical data on 193 consecutive patients with PANS followed up within the Stanford Immune Behavioral Health Clinic from September 1, 2012, to December 31, 2021. Main Outcomes and Measures Medical records were reviewed, and a predefined set of immune markers that were measured during a flare and the features and imaging findings of arthritis and other autoimmune diseases were collected. Immune activation markers included (1) autoimmunity signs (antinuclear antibody, antihistone antibody, antithyroglobulin antibody, C1q binding assay, and complement levels [C3 and C4]); (2) immune dysregulation or inflammation signs (leukopenia, thrombocytosis, C-reactive protein, and erythrocyte sedimentation rate); and (3) vasculopathy signs (livedo reticularis, periungual redness and swelling, abnormally prominent onychodermal band, palatal petechiae, high von Willebrand factor antigen, and high d-dimer). Last, the cumulative risk of developing arthritis and autoimmune diseases was estimated using product limit (Kaplan-Meier) survival probability. Results The study included data from 193 children (112 boys [58.0%]) who had PANS at a mean (SD) age of 7.5 (3.5) years. They were followed up for a mean (SD) of 4.0 (2.1) years. Among those tested for immune activation markers, 54.2% (97 of 179) had nonspecific markers of autoimmunity, 12.0% (22 of 184) had nonspecific signs of immune dysregulation or inflammation, and 35.8% (69 of 193) had signs of vasculopathy. By 14 years of age, the estimated cumulative incidence of arthritis was 28.3% (95% CI, 20.8%-36.3%), and the estimated cumulative incidence of another autoimmune disease was 7.5% (95% CI, 4.0%-12.4%). Novel findings in the subgroup with arthritis include joint capsule thickening (55.0% [22 of 40]), distal interphalangeal joint tenderness (81.8% [45 of 55]), and spinous process tenderness (80.0% [44 of 55]). Among the 55 patients with arthritis, the most common subtypes of arthritis included enthesitis-related arthritis (37 [67.3%]), spondyloarthritis (27 [49.1%]), and psoriatic arthritis (10 [18.2%]). Conclusions and Relevance This study found that patients with PANS show signs of immune activation and vasculopathy during psychiatric symptom flares and have an increased risk of developing arthritis and other autoimmune diseases compared with the general pediatric population. The most common arthritis subtype was enthesitis-related arthritis. These findings suggest that PANS may be part of a multisystem inflammatory condition rather than an isolated psychiatric or neuroinflammatory disorder.
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Affiliation(s)
- Meiqian Ma
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
| | - Erin E. Masterson
- Department of Environmental & Occupational Health Sciences, School of Public Health, University of Washington, Seattle
| | - Jaynelle Gao
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
| | - Hannah Karpel
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
| | - Avis Chan
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
| | - Rajdeep Pooni
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Jesse Sandberg
- Pediatric Division of Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Erika Rubesova
- Pediatric Division of Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
| | - Theresa Willet
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
| | - Yuhuan Xie
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
- Division of Child & Adolescent Psychiatry, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Paula Tran
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
- Division of Child & Adolescent Psychiatry, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Melissa Silverman
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
- Division of Child & Adolescent Psychiatry, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
- Division of Child & Adolescent Psychiatry, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Mellins
- Department of Pediatrics, Program in Immunology, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
- Stanford Immune Behavioral Health Clinic and Research Program at Lucile Packard Children’s Hospital, Palo Alto, California
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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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O'Dor SL, Zagaroli JS, Belisle RM, Hamel MA, Downer OM, Homayoun S, Williams KA. The COVID-19 pandemic and children with PANS/PANDAS: an evaluation of symptom severity, telehealth, and vaccination hesitancy. Child Psychiatry Hum Dev 2024; 55:327-335. [PMID: 35930178 PMCID: PMC9361990 DOI: 10.1007/s10578-022-01401-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
The current study assessed the impact of the COVID-19 pandemic on children with PANS/PANDAS, a condition characterized by sudden-onset obsessive-compulsive, tic, or restrictive eating symptoms following infection. We conducted an anonymous survey between February and June 2021 of 254 self-reported caregivers of minors with PANS/PANDAS. Caregivers answered questions regarding PANS/PANDAS symptoms, telehealth care, and intention to vaccinate their child against COVID-19. PANS/PANDAS symptoms during COVID-19 infections were assessed when applicable. Children's OCD symptoms and coercive behaviors towards caregivers, along with the caregivers' mental health, relationship satisfaction, and burden, were assessed using standardized questionnaires. A majority of respondents endorsed a negative impact on their child's friendships, relationships with extended family, hobbies, and academic skills due to the pandemic. Children with suspected or diagnosed COVID-19 experienced new or worsened psychiatric symptoms, particularly mood lability, OCD, and anxiety. Telehealth care was the preferred treatment modality if the child had mild symptoms of PANS/PANDAS. A majority of caregivers reported high levels of relationship dissatisfaction and caregiver burden. As expected, these data suggest an overall negative impact of the COVID-19 pandemic on children with PANS/PANDAS and their caregivers.
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Affiliation(s)
- Sarah L O'Dor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
- Yawkey Outpatient Center, Massachusetts General Hospital, Suite 6A, 55 Fruit St, 02114, Boston, MA, USA.
| | - J S Zagaroli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - R M Belisle
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - M A Hamel
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - O M Downer
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - S Homayoun
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - K A Williams
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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6
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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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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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La Bella S, Attanasi M, Di Ludovico A, Scorrano G, Mainieri F, Ciarelli F, Lauriola F, Silvestrini L, Girlando V, Chiarelli F, Breda L. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Syndrome: A 10-Year Retrospective Cohort Study in an Italian Centre of Pediatric Rheumatology. Microorganisms 2023; 12:8. [PMID: 38276178 PMCID: PMC10818999 DOI: 10.3390/microorganisms12010008] [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: 11/30/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is a rare pediatric disorder consisting of a sudden onset of obsessive-compulsive disorder (OCD) and/or tics after a group A Streptococcus (GAS) infection. METHODS In the period between 2013 and 2023, 61 children presented to our Pediatric Rheumatology unit with a suspicion of PANDAS syndrome. Among these, a retrospective analysis was conducted, and 19 fulfilled the current classification criteria and were included in this study. RESULTS The male-to-female ratio was 14:5, the median age at onset was 7.0 (2.0-9.5) years, and the median age at diagnosis was 8.0 (3.0-10.4) years. The median follow-up period was 16.0 (6.0-72.0) months. Family and personal history were relevant in 7/19 and 6/19 patients. Tics were present in all patients. Details for motor tics were retrospectively available in 18/19 patients, with the eyes (11/18) and neck/head (10/18) being most often involved. Vocal tics were documented in 8/19, behavioral changes in 10/19, and OCD in 2/19. Regarding the therapeutic response, all patients responded to amoxicillin, 12/13 to benzathine benzylpenicillin, and 7/9 to azithromycin. CONCLUSIONS Our findings partially overlap with previous reports. Larger prospective studies are needed to improve treatment strategies and classification criteria.
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Affiliation(s)
| | - Marina Attanasi
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
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Schön UK. Young adults' experiences of living with paediatric acute-onset neuropsychiatric syndrome. An interview study. Int J Qual Stud Health Well-being 2023; 18:2267268. [PMID: 37816175 PMCID: PMC10566402 DOI: 10.1080/17482631.2023.2267268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023] Open
Abstract
AIM This article explores experiential knowledge of living with paediatric acute-onset neuropsychiatric syndrome (PANS), and the factors that are associated with perceived good care. METHODS Ten people with lived experience of PANS participated, five women and five men aged 19-34. Semi-structured interviews were used to explore their experience of living with PANS and their encounters with healthcare. Thematic analysis was carried out to identify central themes in the transcribed interviews. RESULTS The study revealed a group of young adults living fairly isolated lives, dependent on care from relatives. To them, the illness was a tangible presence. They perceived a lack of knowledge among healthcare staff on PANS in healthcare, and negative consequences linked to this. In addition, their experience-based knowledge of their own illness is devalued in healthcare encounters. A feeling of being pushed around in healthcare, without anyone taking responsibility for the treatment, emerged in the interviews. The participants emphasized the need for increased knowledge among staff to identify PANS and be able to offer effective treatment. CONCLUSION There is a need to increase the knowledge about PANS in healthcare and to coordinating care between neurology, immunology and psychiatry. To be able to offer evidence-based care to children with PANS, in-depth knowledge is needed about aetiology, treatment effects, and user experiences and preferences.
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Affiliation(s)
- Ulla-Karin Schön
- Department of Social Work, Stockholm University, Stockholm, Sweden
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Calaprice-Whitty D, Tang A, Tona J. Factors Associated with Symptom Persistence in PANS: Part I-Access to Care. J Child Adolesc Psychopharmacol 2023; 33:356-364. [PMID: 37902790 DOI: 10.1089/cap.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Objective: Pediatric acute-onset neuropsychiatric syndrome (PANS) presents with abrupt neuropsychiatric symptoms, often after an immunologic trigger. A 2017 survey of 698 subjects found diagnostic delays to be associated with recurrences, suggesting that timely care impacts course. This secondary analysis explores the impact of barriers to care on symptom persistence. Methods: A 146-question online survey gathered history, symptomatology, intervention, and outcome data from subjects with PANS. Multivariate analyses examined associations between symptom persistence over the entire reported disease course, measured as % days symptom-free over reporting periods averaging approximately 4 years, and access-to-care history, reflected in availability of medical expertise and affordability of care. The impacts of time from symptom onset to treatment and effectiveness of initial antibiotics were also examined. Results: Among the 646 subjects analyzed, greater symptom persistence was associated with longer intervals between symptom onset and treatment (F = 4.43, p = 0.002). Thirty-four percent of subjects with the least symptom persistence (>75% symptom-free days), versus 13% of those with the most (symptoms every day), had been diagnosed by the first practitioner seen (likelihood ratio [L-R] χ2 = 36.55, p < 0.0001, for comparison across all groups). Diagnosis and treatment had not been impeded by lack of access to expertise for 52% of subjects with the least persistent symptoms, versus 22% of those with the most (L-R χ2 = 22.47, p < 0.0001). Affordability had not impacted diagnosis and treatment for 76% of subjects with the least persistent symptoms, versus 42% of those with the most (L-R χ2 = 27.83, p < 0.0001). The subjects whose PANS symptoms resolved with antibiotic treatment of the inciting infection experienced less symptom persistence than others (χ2 = 23.27, p = 0.0001). More persistently symptomatic subjects were more likely to have discontinued intravenous immunoglobulin (IVIG) treatment for access-to-care reasons. Conclusions: Unimpeded access to care for PANS is associated with more symptom-free days over reporting periods averaging approximately 4 years. Difficulty reaching expert providers, missed opportunities for diagnoses, and financial limitations may worsen outcomes. Practitioners, particularly primary providers, should adhere to published diagnostic and treatment guidelines promptly upon presentation.
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Affiliation(s)
- Denise Calaprice-Whitty
- Division of Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
- Brain Inflammation Collaborative, Delafield, Wisconsin, USA
| | - Angela Tang
- Division of Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Janice Tona
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
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11
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Calaprice-Whitty D, Tang A, Tona J. Factors Associated with Symptom Persistence in PANS: Part II-Presenting Features, Medical Comorbidities, and IVIG Treatment History. J Child Adolesc Psychopharmacol 2023; 33:365-377. [PMID: 37902971 DOI: 10.1089/cap.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
Objective: Individuals with Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) experience neuropsychiatric symptoms following an infection or other trigger. Although PANS is typically described as relapsing-remitting, a large community-based 2017 study revealed a range of courses. The present study examined clinical predictors of symptom persistence, measured as % days symptom-free, in this same sample. Methods: A 146-question online survey gathered histories (infections and other triggers, medical and developmental comorbidities), symptomatology, interventions, and outcomes (including school functioning) of PANS patients. Multivariate analyses were applied to examine associations between these variables and % days symptom-free across the disease course. Results: Among the 646 subjects included, significant relationships were found between greater symptom persistence and higher rates of medical comorbidities (especially rashes, headaches, chronic sinusitis, frequent diarrhea, and immune deficiencies), developmental diagnoses, and respondent-perceived developmental lags. Subjects with greater symptom persistence were significantly more likely to report PANS exacerbations associated with infections in close contacts, vaccinations, environmental triggers, and exacerbations of comorbidities and were more likely to report PANS recurrences triggered by Epstein Barr Virus, mycoplasma, and sinus infections. More persistent PANS was also associated with significantly higher frequencies of certain symptoms (sleep disturbance, urinary incontinence, muscle pain, brain fog, sensory defensiveness, irritability, and aggression-related symptoms), less effectiveness of intravenous immunoglobulin in combating symptoms, and more difficulty attending school. Conclusions: Our results suggest high symptom persistence in PANS to be associated with more pervasive medical and neuropsychiatric symptoms. Differences in symptom persistence are associated with both intrinsic (e.g., immune competence) and extrinsic (e.g., infections, treatment) factors. Because extrinsic factors are potentially modifiable, it is critical that providers be aware of current guidelines on PANS evaluation and treatment.
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Affiliation(s)
- Denise Calaprice-Whitty
- Division of Rheumatology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California, USA
- Brain Inflammation Collaborative, Delafield, Wisconsin, USA
| | - Angela Tang
- Division of Rheumatology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California, USA
| | - Janice Tona
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
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12
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Eremija J, Patel S, Rice S, Daines M. Intravenous immunoglobulin treatment improves multiple neuropsychiatric outcomes in patients with pediatric acute-onset neuropsychiatric syndrome. Front Pediatr 2023; 11:1229150. [PMID: 37908968 PMCID: PMC10613689 DOI: 10.3389/fped.2023.1229150] [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] [Received: 06/21/2023] [Accepted: 10/03/2023] [Indexed: 11/02/2023] Open
Abstract
Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) is defined by acute onset of diverse neuropsychiatric manifestations, presumably in the setting of underlying immune dysfunction. We used standardized neuropsychological testing to assess how intravenous immunoglobulins (IVIG) impact neurological and cognitive functions in PANS patients by comparing pretreatment with post-treatment scores. A 5-year retrospective study was undertaken in Children's Postinfectious Autoimmune Encephalopathy Center at University of Arizona. We identified 12 children diagnosed with PANS and treated with immunomodulatory IVIG doses, who also completed neuropsychological testing before and after treatment. We tracked multiple patient characteristics, type/timeline of testing, and number of IVIG courses. Score change of 1 standard deviation in any tested domain/subdomain was considered improvement. We further reviewed records for laboratory signs of triggering infection and immune dysfunction. Improvement occurred in 11/12 patients, in one or multiple domains/subdomains, independently of time between disease onset and IVIG initiation (0-7 years). Participants received 1-7 IVIG courses. Improvement was primarily seen in memory (58%), sensory-motor (37%) and visual-motor integration (30%). In 5/12 patients we detected hypogammaglobulinemia requiring ongoing IVIG replacement, one patient had isolated low IgA. Only one patient had to discontinue IVIG therapy due to severe adverse effects. Standardized neuropsychological testing represents an important tool to objectively measure improvement in PANS patients. IVIG was tolerated well and showed efficacy in the vast majority of participants, independently from timelapse since disease onset, emphasizing impact of immunomodulation in PANS. Significant presence of baseline hypogammaglobulinemia in children with PANS emphasizes the presumed role of immune dysfunction in disease pathogenesis.
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Affiliation(s)
- Jelena Eremija
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Sanjay Patel
- Department of Internal Medicine, Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, United States
| | - Sydney Rice
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Michael Daines
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of Arizona, Tucson, AZ, United States
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13
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La Bella S, Scorrano G, Rinaldi M, Di Ludovico A, Mainieri F, Attanasi M, Spalice A, Chiarelli F, Breda L. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): Myth or Reality? The State of the Art on a Controversial Disease. Microorganisms 2023; 11:2549. [PMID: 37894207 PMCID: PMC10609001 DOI: 10.3390/microorganisms11102549] [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: 09/13/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is one of the most controversial diseases in pediatric rheumatology. Despite first being described more than 25 years ago as the sudden and rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorder symptoms as complications of a Group A beta-hemolytic Streptococcus (GAS) infection, precise epidemiological data are still lacking, and there are no strong recommendations for its treatment. Recent advances in the comprehension of PANDAS pathophysiology are largely attributable to animal model studies and the understanding of the roles of Ca++/calmodulin-dependent protein kinase (CaM kinase) II, disrupted dopamine release in the basal ganglia, and striatal cholinergic interneurons. The diagnosis of PANDAS should be made after an exclusion process and should include prepubescent children with a sudden onset of OCD and/or a tic disorder, with a relapsing/remitting disease course, a clear temporal association between GAS infection and onset or exacerbation of symptoms, and the association with other neurological abnormalities such as motoric hyperactivity and choreiform movements. Antibiotic medications are the primary therapeutic modality. Nonetheless, there is a paucity of randomized studies and validated data, resulting in a scarcity of solid recommendations.
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Affiliation(s)
- Saverio La Bella
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Giovanna Scorrano
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marta Rinaldi
- Department of Pediatrics, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK
| | - Armando Di Ludovico
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesca Mainieri
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marina Attanasi
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Luciana Breda
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
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14
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Vreeland A, Calaprice D, Or-Geva N, Frye RE, Agalliu D, Lachman HM, Pittenger C, Pallanti S, Williams K, Ma M, Thienemann M, Gagliano A, Mellins E, Frankovich J. Postinfectious Inflammation, Autoimmunity, and Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection, and Pediatric Acute-Onset Neuropsychiatric Disorder. Dev Neurosci 2023; 45:361-374. [PMID: 37742615 DOI: 10.1159/000534261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023] Open
Abstract
Postinfectious neuroinflammation has been implicated in multiple models of acute-onset obsessive-compulsive disorder including Sydenham chorea (SC), pediatric acute-onset neuropsychiatric syndrome (PANS), and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). These conditions are associated with a range of autoantibodies which are thought to be triggered by infections, most notably group A streptococci (GAS). Based on animal models using huma sera, these autoantibodies are thought to cross-react with neural antigens in the basal ganglia and modulate neuronal activity and behavior. As is true for many childhood neuroinflammatory diseases and rheumatological diseases, SC, PANS, and PANDAS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. In this review article, we outline the accumulating evidence supporting the role neuroinflammation plays in these disorders. We describe work with animal models including patient-derived anti-neuronal autoantibodies, and we outline imaging studies that show alterations in the basal ganglia. In addition, we present research on metabolites, which are helpful in deciphering functional phenotypes, and on the implication of sleep in these disorders. Finally, we encourage future researchers to collaborate across medical specialties (e.g., pediatrics, psychiatry, rheumatology, immunology, and infectious disease) in order to further research on clinical syndromes presenting with neuropsychiatric manifestations.
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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, Palo Alto, California, USA
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Noga Or-Geva
- Interdepartmental Program in Immunology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Richard E Frye
- Autism Discovery and Treatment Foundation, Phoenix, Arizona, USA
| | - Dritan Agalliu
- Department of Neurology, Pathology and Cell Biology, Columbia University Irving School of Medicine, New York, New York, USA
| | - Herbert M Lachman
- Departments of Psychiatry, Medicine, Genetics, and Neuroscience, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Christopher Pittenger
- Departments of Psychiatry and Psychology, Child Study Center and Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Kyle Williams
- Department of Psychiatry Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meiqian Ma
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Margo Thienemann
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Antonella Gagliano
- Division of Child Neurology and Psychiatry, Pediatric Department of Policlinico G. Matino, University of Messina, Messina, Italy
| | - Elizabeth Mellins
- Department of Pediatrics, Program in Immunology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Frankovich
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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15
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Kulumani Mahadevan LS, Murphy M, Selenica M, Latimer E, Harris BT. Clinicopathologic Characteristics of PANDAS in a Young Adult: A Case Report. Dev Neurosci 2023; 45:335-341. [PMID: 37699369 PMCID: PMC10753865 DOI: 10.1159/000534061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Abstract
Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is an acute onset or exacerbation of neuropsychiatric symptoms following a group A streptococcus infection. It is believed to be a result of autoimmune response to streptococcal infection, but there is insufficient evidence to fully support this theory. Although this disease is primarily thought to be a disease of childhood, it is reported to occur also in adults. PANDAS is a well-defined clinical entity, but the neuropathology of this condition has not been established yet. We describe the clinical course of a 26-year-old female diagnosed with PANDAS. She committed suicide and her brain was biobanked for further studies. We examined the banked tissue and performed special stains, immunohistochemical, and immunofluorescence analyses to characterize the neuropathology of this condition. Histology of the temporal lobes, hippocampus, and basal ganglia shows mild gliosis and Alzheimer's type II astrocytes. Acute hypoxic ischemic changes were noted in hippocampus CA1 and CA2 areas. Immunostaining shows increased parenchymal/perivascular GFAP staining and many vessels with mild increases in CD3-, CD4-, and CD25-stained lymphocytes in the basal ganglia. The findings suggest that CD4- and CD25-positive T cells might have an important role in understanding the neuroinflammation and pathogenesis of this condition. The case represents the first neuropathological evaluation report for PANDAS.
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Affiliation(s)
| | | | - Marina Selenica
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Elizabeth Latimer
- Latimer Neurology Center, Washington, DC, USA
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Brent T. Harris
- Department of Pathology, Medstar Georgetown University Hospital, Washington, DC, USA
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
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16
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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: 7] [Impact Index Per Article: 7.0] [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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17
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LaRusso M, Gallego-Pérez DF, Abadía-Barrero CE. Untimely care: How the modern logics of coverage and medicine compromise children's health and development. Soc Sci Med 2023; 319:114962. [PMID: 35584978 DOI: 10.1016/j.socscimed.2022.114962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/22/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022]
Abstract
How do families manage when health care systems do not "cover" and clinicians do not acknowledge their children's condition? This article presents an ethnographic study in the Northeastern region of the United States with 20 families with children diagnosed with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)/Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Two of the 20 families had moved to the U.S. seeking care. The for-profit structure of the U.S. health care system resulted in costly and lengthy therapeutic journeys to access a diagnosis and adequate treatments. In the U.S., PANS/PANDAS coverage depends on legislation, advocacy, clinical characteristics of each child, and how for-profit insurance companies react to an increased demand for a given service. Many medical professionals, both in the U.S. and in other countries, refuse to acknowledge the condition or offer effective treatments that lack "acceptable" evidence. We argue that the financial logic behind coverage exists across modern health care systems and imposes restrictions and exclusions that impede access to care. Thus, untimely care, the time gap from PANS/PANDAS symptoms to diagnosis and treatment is the result of the modern logics that structure medicine and coverage. The results of this study illustrate how modern medicine and coverage fail to protect families with children with PANS/PANDAS against catastrophic expenses and often block care that would prevent developmental disruptions and losses, avoid much suffering, and even save costs to health care systems. New and controversial conditions like PANS/PANDAS highlight the importance of separating the financial logics behind proposals such as "universal health coverage" from the provision of comprehensive forms of care that acknowledge uncertainty and prioritize action and flexibility.
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Affiliation(s)
- Maria LaRusso
- Human Development and Family Sciences, University of Connecticut, USA
| | - Daniel F Gallego-Pérez
- Department of Physical Medicine & Rehabilitation, University of North Carolina School of Medicine, USA
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18
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Ringer N, Roll-Pettersson L. Understanding parental stress among parents of children with Paediatric Acute-onset Neuropsychiatric Syndrome (PANS) in Sweden. Int J Qual Stud Health Well-being 2022; 17:2080906. [PMID: 35616601 PMCID: PMC9673801 DOI: 10.1080/17482631.2022.2080906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Purpose Paediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a relatively new diagnosis characterized by an abrupt and dramatic onset of obsessive-compulsive disorder (OCD), together with neuropsychiatric symptoms. Very little research has been done to understand the experience of being a parent of a child with PANS. The current study aimed to explore aspects related to parental stress in parents of children with PANS. Method The study employed in-depth semi-structured individual interviews with 13 parents of children diagnosed with PANS. Parents were recruited via an announcement on the websites of patient organizations, and in waiting rooms at child medical clinics. An inductive qualitative content analysis approach was used as a guide for analysis of data. Results The analysis of interviews identified five categories of parents’ experiences of stress related to: (1) being effected by the symptoms; (2) experiencing the symptoms over and over again; (3) having no control; (4) obtaining medical treatment is challenging; and (5) managing problems. The results are discussed in relation to the Transactional Theory of Stress and Coping. Conclusions the study illuminates how parents’ perceptions of the child’s symptoms, parents’ strategies for managing problems, as well as experiences related to healthcare providers, may increase or decrease parental stress.
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Affiliation(s)
- Noam Ringer
- Department of Special Education, Stockholm University, Stockholm, Sweden
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19
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Efe A. SARS-CoV-2/COVID-19 associated pediatric acute-onset neuropsychiatric syndrome a case report of female twin adolescents. PSYCHIATRY RESEARCH CASE REPORTS 2022; 1:100074. [PMID: 36267397 PMCID: PMC9562621 DOI: 10.1016/j.psycr.2022.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/07/2022]
Abstract
“Pediatric acute-onset neuropsychiatric syndrome”, or PANS, is a rare syndrome characterized by an acute onset of obsessive-compulsive disorder (OCD), and/or severely restricted food intake accompanied by a variety of neuropsychiatric symptoms. To our knowledge, this is the first case report of twin adolescents with COVID-19-associated PANS. Dizygotic twin sisters in late teens, with abrupt and acute onset of severely restrictive food intake, weight loss, OCD, anxiety with intermittent auditory and visual hallucinations, depression, attention deficit, and sleep disturbances, simultaneously accompanied by milder neurologic symptoms such as hand tremor, tinnitus, dizziness, headache, and weakness of proximal muscles, were applied to child and adolescent psychiatry clinic. The only relevant agent underlying those neuropsychiatric and somatic complaints was COVID-19, and it was validated with laboratory testing, such as positive IgG titers of SARS-CoV-2 and negative biomarkers for other possible bacterial or viral agents. Generalized epileptic anomaly and a vermian/folial atrophy in the cerebellum were detected in further evaluations. Treatment options consisted of psychotropic agents, antibiotics, antiepileptic, and intravenous immunoglobulin transfusion finely treated the neuropsychiatric symptoms. Clinicians should consider SARS-CoV-2 as a potential agent, when a child presents with abrupt onset, dramatic neuropsychiatric symptoms also consisting of PANS, even in asymptomatic patients or with mild respiratory symptoms.
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20
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Gao J, Chan A, Willett T, Farhadian B, Silverman M, Tran P, Ahmed S, Thienemann M, Frankovich J. Sex and Aggression Characteristics in a Cohort of Patients with Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2022; 32:444-452. [PMID: 35998241 PMCID: PMC9603278 DOI: 10.1089/cap.2021.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective: This study describes for the first time the characteristics by sex of patients with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), including clinical phenotype, treatment, and psychosocial aspects of disease. Methods: This cross-sectional study included 205 consecutive community patients evaluated between January 1, 2012 and March 30, 2019 and compared 87 females with 118 males. Our primary hypothesis was that males would display more aggression, as measured by the Modified Overt Aggression Scale (MOAS) and would be treated with immunotherapy earlier than females. The MOAS began to be administered 5 years into the study period, and 57 of the 205 families completed the MOAS for this study. Results: Our analysis revealed that males had a higher median MOAS score in the first year of clinic when compared with females (median 11, interquartile range [IQR] [4-24] vs. median 3, IQR [1-9]; p = 0.03) and a higher median subscore for physical aggression (median 4, IQR [0-12] vs. median 0, IQR [0-8]; p = 0.05). The median time from PANS symptom onset to first administration of immunotherapy, which did not include nonsteroidal anti-inflammatory drugs or short bursts of oral steroids, was 6.9 years for females and 3.7 years for males (p = 0.20). The two groups did not differ significantly in age of PANS onset, time from onset to clinic entry, other psychiatric symptom measures, or laboratory markers of inflammation. Conclusion: Among patients with PANS, males exhibit more aggressive behavior when compared with females, which may advance the decision to treat with immunotherapy. Scores that capture a more global level of functioning show that despite there being a higher level of aggression in males, female patients with PANS have similar levels of overall impairment.
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Affiliation(s)
- Jaynelle Gao
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Avis Chan
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Theresa Willett
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Bahare Farhadian
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Paula Tran
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Sana Ahmed
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer Frankovich
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
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21
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Hutanu A, Reddy LN, Mathew J, Avanthika C, Jhaveri S, Tummala N. Pediatric Autoimmune Neuropsychiatric Disorders Associated With Group A Streptococci: Etiopathology and Diagnostic Challenges. Cureus 2022; 14:e27729. [PMID: 36106298 PMCID: PMC9447625 DOI: 10.7759/cureus.27729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2022] [Indexed: 11/06/2022] Open
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) have attracted a lot of interest and discussion since it was originally characterized in 1998. The role of streptococcal infection in children with abrupt-onset obsessive-compulsive disorder (OCD) and new-onset tics, the natural history of this entity, and the role of symptomatic and disease-modifying therapies, such as antibiotics, immunotherapy, and psychoactive drugs, are still unresolved issues. Alternative therapies for acute-onset OCD have been developed based on this postulated pathophysiology, including antibiotics and immunomodulatory therapy. The literature on PANDAS therapy is varied but there is no clinical consensus on the treatment of choice. While there is no convincing evidence for the autoimmune rationale for PANDAS, given the increased attention to this entity and the apparent growth in usage of this diagnostic category, it is critical to address concerns about the condition's diagnosis, treatment, and pathogenesis. We conducted a multi-language literature search on Medline, Cochrane, Embase, and Google Scholar for a period spanning until October 2021. The following search strings and Medical Subject Heading (MeSH) terms were used: "PANDAS," "Group A Streptococcus," "OCD," and "tics." We explored the literature on PANDAS in terms of its epidemiology, pathophysiology, the role of group A streptococcal infection, associated complications, and prophylactic and treatment modalities. We examined current working definitions of PANDAS, analyzed differential diagnoses, and published pieces of evidence for therapies associated with this entity, with a view to proposing a therapeutic strategy for children with acute symptoms that meet PANDAS criteria, in this review article.
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Affiliation(s)
- Andrada Hutanu
- Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, GBR
| | | | - Janice Mathew
- Pediatrics, Jubilee Mission Medical College and Research Institute, Thrissur, IND
| | | | - Sharan Jhaveri
- Medicine, Smt. NHL Municipal Medical College, Ahmedabad, IND
| | - Nayanika Tummala
- Internal Medicine, Gitam Institute of Medical Sciences and Research, Vishakapatnam, IND
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22
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Endres D, Pollak TA, Bechter K, Denzel D, Pitsch K, Nickel K, Runge K, Pankratz B, Klatzmann D, Tamouza R, Mallet L, Leboyer M, Prüss H, Voderholzer U, Cunningham JL, Domschke K, Tebartz van Elst L, Schiele MA. Immunological causes of obsessive-compulsive disorder: is it time for the concept of an "autoimmune OCD" subtype? Transl Psychiatry 2022; 12:5. [PMID: 35013105 PMCID: PMC8744027 DOI: 10.1038/s41398-021-01700-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022] Open
Abstract
Obsessive-compulsive disorder (OCD) is a highly disabling mental illness that can be divided into frequent primary and rarer organic secondary forms. Its association with secondary autoimmune triggers was introduced through the discovery of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS) and Pediatric Acute onset Neuropsychiatric Syndrome (PANS). Autoimmune encephalitis and systemic autoimmune diseases or other autoimmune brain diseases, such as multiple sclerosis, have also been reported to sometimes present with obsessive-compulsive symptoms (OCS). Subgroups of patients with OCD show elevated proinflammatory cytokines and autoantibodies against targets that include the basal ganglia. In this conceptual review paper, the clinical manifestations, pathophysiological considerations, diagnostic investigations, and treatment approaches of immune-related secondary OCD are summarized. The novel concept of "autoimmune OCD" is proposed for a small subgroup of OCD patients, and clinical signs based on the PANDAS/PANS criteria and from recent experience with autoimmune encephalitis and autoimmune psychosis are suggested. Red flag signs for "autoimmune OCD" could include (sub)acute onset, unusual age of onset, atypical presentation of OCS with neuropsychiatric features (e.g., disproportionate cognitive deficits) or accompanying neurological symptoms (e.g., movement disorders), autonomic dysfunction, treatment resistance, associations of symptom onset with infections such as group A streptococcus, comorbid autoimmune diseases or malignancies. Clinical investigations may also reveal alterations such as increased levels of anti-basal ganglia or dopamine receptor antibodies or inflammatory changes in the basal ganglia in neuroimaging. Based on these red flag signs, the criteria for a possible, probable, and definite autoimmune OCD subtype are proposed.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Karl Bechter
- Department for Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Dominik Denzel
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karoline Pitsch
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kimon Runge
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Pankratz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Klatzmann
- AP-HP, Hôpital Pitié-Salpêtrière, Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (i2B), Paris, France
- Sorbonne Université, INSERM, Immunology-Immunopathology-Immunotherapy (i3), Paris, France
| | - Ryad Tamouza
- Univ Paris Est Créteil, INSERM, IMRB, Translational Neuropsychiatry, AP-HP, DMU IMPACT, FHU ADAPT, Fondation FondaMental, Créteil, France
| | - Luc Mallet
- Univ Paris Est Créteil, INSERM, IMRB, Translational Neuropsychiatry, AP-HP, DMU IMPACT, FHU ADAPT, Fondation FondaMental, Créteil, France
| | - Marion Leboyer
- Univ Paris Est Créteil, INSERM, IMRB, Translational Neuropsychiatry, AP-HP, DMU IMPACT, FHU ADAPT, Fondation FondaMental, Créteil, France
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Ulrich Voderholzer
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital Munich, Munich, Germany
| | - Janet L Cunningham
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Centre for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Miriam A Schiele
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Méneret A, Garcin B, Frismand S, Lannuzel A, Mariani LL, Roze E. Treatable Hyperkinetic Movement Disorders Not to Be Missed. Front Neurol 2021; 12:659805. [PMID: 34925200 PMCID: PMC8671871 DOI: 10.3389/fneur.2021.659805] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022] Open
Abstract
Hyperkinetic movement disorders are characterized by the presence of abnormal involuntary movements, comprising most notably dystonia, chorea, myoclonus, and tremor. Possible causes are numerous, including autoimmune disorders, infections of the central nervous system, metabolic disturbances, genetic diseases, drug-related causes and functional disorders, making the diagnostic process difficult for clinicians. Some diagnoses may be delayed without serious consequences, but diagnosis delays may prove detrimental in treatable disorders, ranging from functional disabilities, as in dopa-responsive dystonia, to death, as in Whipple's disease. In this review, we focus on treatable disorders that may present with prominent hyperkinetic movement disorders.
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Affiliation(s)
- Aurélie Méneret
- Département de Neurologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
| | - Béatrice Garcin
- Service de Neurologie, Hôpital Avicenne, APHP, Bobigny, France
| | - Solène Frismand
- Département de Neurologie, Hôpital universitaire de Nancy, Nancy, France
| | - Annie Lannuzel
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
- Département de Neurologie, Centre Hospitalier Universitaire de la Guadeloupe, Pointe-à-Pitre, France
- Faculté de Médecine, Université Des Antilles, Pointe-à-Pitre, France
- Centre D'investigation Clinique Antilles Guyane, Pointe-à-Pitre, France
| | - Louise-Laure Mariani
- Département de Neurologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
| | - Emmanuel Roze
- Département de Neurologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
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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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Johnson M, Ehlers S, Fernell E, Hajjari P, Wartenberg C, Wallerstedt SM. Anti-inflammatory, antibacterial and immunomodulatory treatment in children with symptoms corresponding to the research condition PANS (Pediatric Acute-onset Neuropsychiatric Syndrome): A systematic review. PLoS One 2021; 16:e0253844. [PMID: 34197525 PMCID: PMC8248649 DOI: 10.1371/journal.pone.0253844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 06/15/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To assess effects of treatment against a hypothesized neuroinflammation in children with symptoms corresponding to the research condition Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) which is not included in current diagnostic systems. METHODS Systematic literature searches were performed (1998 to June 2020) in PubMed, Embase, the Cochrane Library, CINAHL, PsycInfo, and HTA databases. Inclusion criteria: patients (P) were children (<18 years) with PANS; intervention (I)/comparison (C) was use of, versus no use of, anti-inflammatory, antibacterial or immunomodulating treatments; outcomes (O) were health-related quality of life (HRQL), level of functioning, symptom change, and complications. RESULTS Four randomised controlled trials (RCTs) and three non-RCTs, including 23 to 98 patients, fulfilled the PICO. HRQL was not investigated in any study. Regarding level of functioning, two RCTs investigated antibiotics (penicillin V, azithromycin) and one RCT investigated immunomodulating treatments (intravenous immunoglobulins (IVIG), plasma exchange). Regarding symptoms, two non-RCTs investigated anti-inflammatory treatment (cyclooxygenase (COX) inhibitors, corticosteroids), two RCTs and one non-RCT investigated antibiotics (penicillin V, azithromycin), and two RCTs investigated immunomodulating treatments (IVIG, plasma exchange). Complications, reported in five studies, were consistent with those listed in the summary of products characteristics (SPC). All studies were assessed to have some or major problems regarding directness, the absence of an established diagnosis contributing to clinical diversity in the studied populations. All studies were assessed to have major risk of bias, including selection and detection biases. Due to clinical and methodological diversity, meta-analyses were not performed. CONCLUSION This systematic review reveals very low certainty of evidence of beneficial effects, and moderate certainty of evidence of adverse effects, of anti-inflammatory, antibacterial or immunomodulating treatments in patients with symptoms corresponding to the research condition PANS. Available evidence neither supports nor excludes potential beneficial effects, but supports that such treatment can result in adverse effects. REGISTRATION PROSPERO (CRD42020155714).
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Affiliation(s)
- Mats Johnson
- Child Neuropsychiatry Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stephan Ehlers
- Regional Knowledge Center for Mental Health, Gothenburg, Sweden
| | - Elisabeth Fernell
- Child Neuropsychiatry Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Constanze Wartenberg
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Susanna M. Wallerstedt
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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26
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Melamed I, Kobayashi RH, O'Connor M, Kobayashi AL, Schechterman A, Heffron M, Canterberry S, Miranda H, Rashid N. Evaluation of Intravenous Immunoglobulin in Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2021; 31:118-128. [PMID: 33601937 PMCID: PMC7984935 DOI: 10.1089/cap.2020.0100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a clinical diagnosis in children who have an acute manifestation of varied neuropsychiatric symptoms, including obsessive compulsive disorder, eating disorders, tics, anxiety, irritability, and problems with attention/concentration. PANS may develop as a result of a postinfectious syndrome and may represent a new form of postinfectious autoimmunity. To test the hypothesis that multiple, consecutive infusions of intravenous immunoglobulin (IVIG) for PANS can be efficacious, a multisite, open-label study was designed. Methods: The primary endpoint was evaluation of the efficacy of IVIG [Octagam 5%] in PANS over a period of 6 months (six infusions) based on mean changes in psychological evaluation scores using 6 different assessments, including the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Clinical Global Impression of Severity, and the Parent-Rated Pediatric Acute Neuropsychiatric Symptom Scale (PANS Scale). Results: The final cohort consisted of 21 subjects (7 per site) with moderate to severe PANS. The mean age was 10.86 years (range: 4-16 years). Results demonstrated statistically significant reductions in symptoms from baseline to end of treatment in all six assessments measured. CY-BOCS results demonstrated statistically significant reductions in obsessive compulsive symptoms (p < 0.0001), resulting in >50% improvement sustained for at least 8 weeks after the final infusion and up to 46 weeks in a subset of subjects. Conclusions: In PANS, which may be associated with an underlying immune dysregulation, sequential infusions of IVIG [Octagam 5%] successfully ameliorated psychological symptoms and dysfunction, with sustained benefits for at least 8 weeks, and up to 46 weeks in a subset of subjects. In addition, baseline immune and autoimmune profiles demonstrated significant elevations in a majority of subjects, which requires further evaluation, characterization, and study to clarify the potential immune dysfunction by which PANS manifests and progresses.
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Affiliation(s)
| | - Roger H. Kobayashi
- Pediatric Immunology & Allergy, University of California, Los Angeles School of Medicine, Los Angeles, California, USA
| | - Maeve O'Connor
- Allergy, Asthma & Immunology Relief, Charlotte, North Carolina, USA
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27
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Cross A, Bouboulis D, Shimasaki C, Jones CR. Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery. Front Psychiatry 2021; 12:505941. [PMID: 33603684 PMCID: PMC7884317 DOI: 10.3389/fpsyt.2021.505941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/04/2021] [Indexed: 12/03/2022] Open
Abstract
This case report describes the diagnosis and treatment of a pre-pubertal (onset at age 7) Caucasian female with serological evidence of Lyme disease accompanied by multiple neuropsychiatric symptoms 6 months following a vacation in a tick endemic area of the United States. Prior to the diagnosis of Lyme disease, the patient also met the clinical diagnostic criteria for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep), with serological evidence of three distinct episodes of streptococcal pharyngitis. All three episodes of strep occurred during the 6-months interval between suspected Lyme disease exposure and the onset of multiple neuropsychiatric symptoms. Her sometimes incapacitating symptoms followed a relapsing and remitting course that impacted her personal, family, social, and academic domains. Over a span of 31 consecutive months of treatment with various antimicrobials and three courses of intravenous immunoglobulins (IVIg) she experienced complete remission and remains symptom free at the time of this publication. Written permission was obtained from the minor patient's mother allowing the submission and publication of this case study.
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Affiliation(s)
- Amy Cross
- Moleculera Labs, Oklahoma City, OK, United States
| | - Denis Bouboulis
- Advanced Allergy, Immunology and Asthma, Darien, CT, United States
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Alm PA. Streptococcal Infection as a Major Historical Cause of Stuttering: Data, Mechanisms, and Current Importance. Front Hum Neurosci 2020; 14:569519. [PMID: 33304252 PMCID: PMC7693426 DOI: 10.3389/fnhum.2020.569519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/24/2020] [Indexed: 12/02/2022] Open
Abstract
Stuttering is one of the most well-known speech disorders, but the underlying neurological mechanisms are debated. In addition to genetic factors, there are also major non-genetic contributions. It is here proposed that infection with group A beta-hemolytic streptococcus (GAS) was a major underlying cause of stuttering until the mid-1900s when penicillin was introduced in 1943. The main mechanism proposed is an autoimmune reaction from tonsillitis, targeting specific molecules, for example within the basal ganglia. It is here also proposed that GAS infections may have continued to cause stuttering to some extent, to the present date, though more rarely. If so, early diagnosis of such cases would be of importance. Childhood cases with sudden onset of stuttering after throat infection may be particularly important to assess for possible GAS infection. The support for this hypothesis primarily comes from three lines of argument. First, medical record data from the 1930s strongly indicates that there was one type of medical event in particular that preceded the onset of childhood stuttering with unexpected frequency: diseases related to GAS throat infections. In particular, this included tonsillitis and scarlet fever, but also rheumatic fever. Rheumatic fever is a childhood autoimmune sequela of GAS infection, which was a relatively widespread medical problem until the early 1960s. Second, available reports of changes of the childhood prevalence of stuttering indicate striking parallels between stuttering and the incidence of rheumatic fever, with: (1) decline from the early 1900s; (2) marked decline from the introduction of penicillin in the mid 1940s; and (3) reaching a more stable level in the 1960s. The correlations between the data for stuttering and rheumatic fever after the introduction of penicillin are very high, at about 0.95. Third, there are established biological mechanisms linking GAS tonsillitis to immunological effects on the brain. Also, a small number of more recent case reports have provided further support for the hypothesis linking stuttering to GAS infection. Overall, it is proposed that the available data provides strong evidence for the hypothesis that GAS infection was a major cause of stuttering until the mid-1900s, interacting with genetic predisposition.
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Affiliation(s)
- Per A. Alm
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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29
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CE: PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection. Am J Nurs 2020; 120:32-37. [PMID: 32665509 DOI: 10.1097/01.naj.0000694332.85367.d0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
If undiagnosed and untreated, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) can suddenly and drastically disrupt the lives of previously healthy children and their families. The key to prompt diagnosis of PANDAS and its appropriate treatment is provider awareness that streptococcal infection may present with neuropsychiatric symptoms. The authors discuss the signs and symptoms that characterize PANDAS, as well as its presumed pathogenesis, and illustrate, through a composite case history, a symptom presentation, diagnostic journey, treatment course, and recovery that is representative of many PANDAS cases.
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30
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The relation between normative rituals/routines and obsessive-compulsive symptoms at a young age: A systematic review. DEVELOPMENTAL REVIEW 2020. [DOI: 10.1016/j.dr.2020.100913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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31
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Figlerowicz M, Mazur-Melewska K, Kemnitz P, Mania A. Pediatric postviral autoimmune disorders of the CNS. Future Virol 2020. [DOI: 10.2217/fvl-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Infections caused by various viruses, mainly belonging to the Herpesviridae family, can trigger the autoimmune process in the CNS in children. This can break brain immune tolerance and induce many molecular and cellular pathways of the immune response. This can lead to the appearance of neuronal auto-antibodies to intracellular, cell-surface or extracellular synaptic antigens. Children may also display a wide spectrum of neurological problems from encephalitis to obsessive–compulsive or tic disorders. In these cases, patients rarely respond to traditional treatment, based on antiviral or/and symptomatic drugs, but early immunotherapy is very effective. The implementation of routine immune tests in all children with acute neurological disorders should be recommended.
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Affiliation(s)
- Magdalena Figlerowicz
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Paweł Kemnitz
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Anna Mania
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
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32
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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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33
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Shimasaki C, Frye RE, Trifiletti R, Cooperstock M, Kaplan G, Melamed I, Greenberg R, Katz A, Fier E, Kem D, Traver D, Dempsey T, Latimer ME, Cross A, Dunn JP, Bentley R, Alvarez K, Reim S, Appleman J. Evaluation of the Cunningham Panel™ in pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS): Changes in antineuronal antibody titers parallel changes in patient symptoms. J Neuroimmunol 2019; 339:577138. [PMID: 31884258 DOI: 10.1016/j.jneuroim.2019.577138] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 12/12/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This retrospective study examined whether changes in patient pre- and post-treatment symptoms correlated with changes in anti-neuronal autoantibody titers and the neuronal cell stimulation assay in the Cunningham Panel in patients with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS), and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). METHODS In an analysis of all tests consecutively performed in Moleculera Labs' clinical laboratory from April 22, 2013 to December 31, 2016, we identified 206 patients who were prescribed at least one panel prior to and following treatment, and who met the PANDAS/PANS diagnostic criteria. Patient follow-up was performed to collect symptoms and treatment or medical intervention. Of the 206 patients, 58 met the inclusion criteria of providing informed consent/assent and documented pre- and post-treatment symptoms. Clinician and parent-reported symptoms after treatment or medical intervention were categorized as "Improved/Resolved" (n = 34) or "Not-Improved/Worsened" (n = 24). These were analyzed for any association between changes in clinical status and changes in Cunningham panel test results. Clinical assay performance was also evaluated for reproducibility and reliability. RESULTS Comparison of pre- and post-treatment status revealed that the Cunningham Panel results correlated with changes in patient's neuropsychiatric symptoms. Based upon the change in the number of positive tests, the overall accuracy was 86%, the sensitivity and specificity were 88% and 83% respectively, and the Area Under the Curve (AUC) was 93.4%. When evaluated by changes in autoantibody levels, we observed an overall accuracy of 90%, a sensitivity of 88%, a specificity of 92% and an AUC of 95.7%. Assay reproducibility for the calcium/calmodulin-dependent protein kinase II (CaMKII) revealed a correlation coefficient of 0.90 (p < 1.67 × 10-6) and the ELISA assays demonstrated test-retest reproducibility comparable with other ELISA assays. CONCLUSION This study revealed a strong positive association between changes in neuropsychiatric symptoms and changes in the level of anti-neuronal antibodies and antibody-mediated CaMKII human neuronal cell activation. These results suggest there may be clinical utility in monitoring autoantibody levels and stimulatory activity against these five neuronal antigen targets as an aid in the diagnosis and treatment of infection-triggered autoimmune neuropsychiatric disorders. Future prospective studies should examine the feasibility of predicting antimicrobial and immunotherapy responses with the Cunningham Panel.
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Affiliation(s)
- Craig Shimasaki
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America.
| | - Richard E Frye
- Barrow Neurological Institute, Phoenix Children's Hospital, 1919 East Thomas Rd, Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Rosario Trifiletti
- The PANS/PANDAS Institute, 545 Island Road, Suite 1D, Ramsey, NJ 07446, United States of America
| | - Michael Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, MO, United States of America
| | - Gary Kaplan
- The Kaplan Center for Integrative Medicine, 6828 Elm Street, Suite 300, McLean, VA 22101, United States of America
| | - Isaac Melamed
- IMMUNOe Health and Research Centers, 6801 South Yosemite Street, Centennial, CO 80112, United States of America
| | - Rosalie Greenberg
- Medical Arts Psychotherapy Associates, P.A., 33 Overlook Road, Suite 406, Summit, NJ 07901, United States of America
| | - Amiram Katz
- Private Practice Neurology, 325 Boston Post Rd., Suite 1D, Orange, CT 06477, United States of America
| | - Eric Fier
- TherapyWorks ATL, 621 North Avenue NE, Atlanta, GA 30308, United States of America
| | - David Kem
- Section of Endocrinology and Diabetes, University of Oklahoma Department of Medicine, 1000 N Lincoln Blvd., Oklahoma City, OK 73104, United States of America
| | - David Traver
- 1261 E. Hillsdale Blvd., Foster City, CA 94404, United States of America
| | - Tania Dempsey
- Armonk Integrative Medicine, Private Practice, Pediatrics, 99 Business Park Drive, Armonk, NY 10504, United States of America
| | - M Elizabeth Latimer
- Latimer Neurology Center, 1101 30th Street NW Suite #320, Washington, DC 20007, United States of America
| | - Amy Cross
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Joshua P Dunn
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Rebecca Bentley
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Kathy Alvarez
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America; The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States of America
| | - Sean Reim
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States of America
| | - James Appleman
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
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Gromark C, Harris RA, Wickström R, Horne A, Silverberg-Mörse M, Serlachius E, Mataix-Cols D. Establishing a Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic: Baseline Clinical Features of the Pediatric Acute-Onset Neuropsychiatric Syndrome Cohort at Karolinska Institutet. J Child Adolesc Psychopharmacol 2019; 29:625-633. [PMID: 31170007 PMCID: PMC6786340 DOI: 10.1089/cap.2018.0127] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a descriptive clinical entity defined by the abrupt onset of psychiatric and somatic symptoms leading to significant loss of function. Data on well-characterized PANS patients are limited, biomarkers have yet to be identified, and a solid evidence base to guide treatment is lacking. In this study, we present our experience of a systematic evaluation of the first 45 patients included in a Swedish cohort. Methods: During the period 2014-2018, our clinic received 100 referrals regarding suspected PANS. All patients underwent a standardized psychiatric/medical evaluation by a child/adolescent psychiatrist and a clinical psychologist or a nurse. Those with severe symptoms were also assessed by a pediatric neurologist and a pediatric rheumatologist. Laboratory tests were obtained at different time points in an attempt to capture an active disease state. Results: Of the 100 referrals, 45 met strict PANS criteria and consented to participate in a long-term follow-up study. The median age at intake was 7.2 years (range 3.0-13.1) and 56% were male. Ninety-three percent fulfilled both criteria for acute/atypical onset of PANS symptoms and having had an infection in relation to onset. Sixteen percent had an onset of an autoimmune or inflammatory disorder in temporal relation to the onset of PANS-related symptoms. The most common onset symptoms were obsessive-compulsive disorder (89%), anxiety (78%), and emotional lability (71%). Twenty-four percent had a preexisting autoimmune disease (AD) and 18% a preexisting psychiatric/neuropsychiatric diagnosis. Sixty-four percent of biological relatives had at least one psychiatric disorder and 76% at least one AD or inflammatory disorder. Complement activation (37%), leukopenia (20%), positive antinuclear antibodies (17%), and elevated thyroid antibodies (11%) were the most common laboratory findings. Conclusions: In our PANS cohort, there was a strong indication of an association with AD. Further work is needed to establish whether any of the potential biomarkers identified will be clinically useful. Long-term follow-up of these patients using the Swedish national registers will enable a deeper understanding of the course of this patient group.
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Affiliation(s)
- Caroline Gromark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Robert A. Harris
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Neurology, Karolinska University Hospital, Solna, Sweden
| | - AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Rheumatology, Karolinska University Hospital, Solna, Sweden
| | - Maria Silverberg-Mörse
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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Hesselmark E, Bejerot S. Patient Satisfaction and Treatments Offered to Swedish Patients with Suspected Pediatric Acute-Onset Neuropsychiatric Syndrome and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. J Child Adolesc Psychopharmacol 2019; 29:634-641. [PMID: 31009235 PMCID: PMC6786336 DOI: 10.1089/cap.2018.0141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are subtypes of Obsessive-Compulsive Disorder (OCD) with suggested autoimmune etiology. Immunomodulatory treatments have been introduced as treatment options. A recent systematic review concluded that the evidence for all treatment options for PANS and PANDAS is inconclusive. However, case reports and clinical experience suggest that antibiotics and immunomodulatory treatment may be helpful. Treatment may also affect the patients' satisfaction with health care services offered. This study aims to describe the treatments given to a cohort of Swedish patients with suspected PANS and PANDAS, the patient rated treatment effects, and to establish if any specific treatment predicts higher patient satisfaction. Methods: Fifty-three patients (m = 33, f = 20, median age = 14, age range = 4-36) with suspected PANS or PANDAS were enrolled and assessed for PANS and PANDAS caseness, treatments given, treatment effects, global improvement, and patient satisfaction. Cases with confirmed and suspected PANS or PANDAS were compared regarding the frequency of treatments given and treatment effect. A linear regression model was used to see if treatments given or global improvement predicted patient satisfaction. Results: Twenty-four participants fulfilled criteria for PANS or PANDAS and 29 did not. The most common treatments given were antibiotics (88%), nonsteroidal anti-inflammatory drugs (67%), cognitive behavioral therapy (53%), and selective serotonin reuptake inhibitors (42%). There were no major differences between confirmed and suspected cases regarding what treatments they had received or their effect. Patient satisfaction was predicted by overall clinical improvement at the time of assessment. Antibiotics and intravenous immunoglobulin (IVIG) were rated as the most successful treatments by participants and were associated with higher patient satisfaction. Conclusions: It was more common that patients had received antibiotics than common psychiatric treatments for their psychiatric symptoms. Antibiotics and IVIG were experienced as effective treatments by the patients. Patient satisfaction was on average moderately low, and higher patient satisfaction was associated with global clinical improvement.
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Affiliation(s)
- Eva Hesselmark
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Susanne Bejerot
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
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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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Melerine C, Ledet LM. PANDAS: What nurses need to know. Nursing 2019; 49:46-49. [PMID: 31343533 DOI: 10.1097/01.nurse.0000559921.99814.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) describes a disorder that develops in children who abruptly develop neurologic abnormalities following a streptococcal infection. The authors discuss what is known about this poorly understood disorder and how nurses can educate and support patients and their families.
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Affiliation(s)
- Chelsea Melerine
- Chelsea Melerine is a recent BSN graduate of the honors program at LSU Health New Orleans School of Nursing in New Orleans, La., where Linda M. Ledet is an assistant professor of clinical nursing
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A Pediatric Infectious Disease Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated With Streptococcal Infection and Pediatric Acute-onset Neuropsychiatric Syndrome. Pediatr Infect Dis J 2019; 38:706-709. [PMID: 30747831 DOI: 10.1097/inf.0000000000002295] [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: 11/25/2022]
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Heavey E, Peterson K. Treating pediatric acute-onset neuropsychiatric syndrome. Nurse Pract 2019; 44:44-49. [PMID: 30789532 DOI: 10.1097/01.npr.0000553400.88847.5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) can be caused by infectious and noninfectious triggers. NPs can help children with PANS recover from their symptoms and prevent future recurrences by appropriately screening, recognizing, and diagnosing the clinical presentation of PANS. PANS treatment includes pharmacologic therapies as well as cognitive behavioral therapy.
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Affiliation(s)
- Elizabeth Heavey
- Elizabeth Heavey is a professor of nursing and graduate program director at The College at Brockport, Brockport, N.Y. Heavey is also a certified nurse-midwife. Kathleen Peterson is a professor of nursing and chair of the department of nursing at The College at Brockport, Brockport, N.Y. Peterson is also a certified pediatric NP
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Silverman M, Frankovich J, Nguyen E, Leibold C, Yoon J, Mark Freeman G, Karpel H, Thienemann M. Psychotic symptoms in youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) may reflect syndrome severity and heterogeneity. J Psychiatr Res 2019; 110:93-102. [PMID: 30605785 DOI: 10.1016/j.jpsychires.2018.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/04/2018] [Accepted: 11/13/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE In the clinical syndrome Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), obsessive compulsive disorder (OCD) and/or food refusal symptoms have an abrupt-onset (over 48 h) coupled with at least two other specified neuropsychiatric symptoms. We aimed to characterize in detail for the first time, psychotic symptoms experienced by children with PANS as well as the impact of psychotic symptoms on disease severity and course of illness. We inform about the diagnosis of the clinical description: PANS and hope to improve evaluation, treatment, diagnostic validity and future investigation. METHODS Retrospective review of 143 consecutive PANS clinic patient charts meeting inclusion criteria. The Caregiver Burden Inventory, Global Impairment Score, and Children's Global Assessment Scale were used to assess impairment. RESULTS Visual and auditory hallucinations were each experienced by 36%, of which most (83%) were transient and complex (non-threatening voices or figures). 6.3% and 5.5% of patients experienced delusions and thought disorganization respectively. Those with psychotic symptoms showed statistically significant differences in disease impairment and caregiver burden. There were no differences in time to treatment access or length of illness. CONCLUSIONS Over 1/3 of children with PANS experienced transient hallucinations. They were more impaired than those without psychotic symptoms, but showed no differences in disease progression. This difference may point toward heterogeneity in PANS. When evaluating children with acute psychotic symptoms, clinicians should screen for abrupt-onset of a symptom cluster including OCD and/or food refusal, with neuropsychiatric symptoms (enuresis, handwriting changes, tics, hyperactivity, sleep disorder) before initiating treatment.
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Affiliation(s)
- Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States.
| | - Jennifer Frankovich
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Emily Nguyen
- Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Collin Leibold
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Jong Yoon
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; VA Palo Alto Health Care System, 3801 Miranda Ave., Building 4, 2nd Floor, Palo Alto, CA, 94304, United States
| | - G Mark Freeman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | - Hannah Karpel
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
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Leibold C, Thienemann M, Farhadian B, Willett T, Frankovich J. Psychometric Properties of the Pediatric Acute-Onset Neuropsychiatric Syndrome Global Impairment Score in Children and Adolescents with Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2019; 29:41-49. [PMID: 30421965 DOI: 10.1089/cap.2018.0029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study validates the caregiver-rated Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) Global Impairment Score (GIS), a single-item, 0-100 scale, for use in PANS. METHODS We collected longitudinal data from community patients meeting PANS criteria. We included 128 patients with 1926 GISs, each from a unique clinic visit. To assess discriminant validity, we compared GISs from patients with PANS with scores from a population of healthy controls. To evaluate external validity, we compared global impairment with a clinician-reported global measure-the Child Global Assessment Scale (CGAS)-using the Bland-Altman plots and correlation coefficients. Then, we evaluated associations between the PANS GIS and symptom-specific disease severity variables by fitting mixed models with repeated measures. RESULTS The GIS shows excellent discriminant validity, distinguishing patients with PANS from healthy controls. The scores on the GIS show an acceptable level of agreement with the clinician-reported CGAS. The regression line in the Bland-Altman plot had a positive slope, indicating that parents tend to report higher disease severity than clinicians at higher levels of disease severity. Correlation was higher during disease remissions than during disease flares (r = -0.69 vs. r = -0.48). All disease severity scales predicted GIS in the expected direction. CONCLUSION The GIS has excellent discriminant validity and acceptable construct validity.
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Affiliation(s)
- Collin Leibold
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California
| | - Margo Thienemann
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,2 Child and Adolescent Psychiatry, Stanford University School of Medicine , Palo Alto, California
| | - Bahare Farhadian
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,3 Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine , Palo Alto, California
| | - Theresa Willett
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,3 Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine , Palo Alto, California
| | - Jennifer Frankovich
- 1 Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine , Palo Alto, California.,3 Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine , Palo Alto, California
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Johnson M, Fernell E, Preda I, Wallin L, Fasth A, Gillberg C, Gillberg C. Paediatric acute-onset neuropsychiatric syndrome in children and adolescents: an observational cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:175-180. [PMID: 30704875 DOI: 10.1016/s2352-4642(18)30404-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Paediatric acute-onset neuropsychiatric syndrome (PANS) is a newly defined symptom-based condition that mainly occurs in children and adolescents. Few studies have described the clinical characteristics of the syndrome. METHODS We clinically assessed and reviewed the medical histories of children and adolescents (aged 4-14 years) with suspected PANS who were referred to a specialist clinic in Gothenburg, Sweden, by local paediatricians and child psychiatrists. We scored severity of symptoms and impairment retrospectively for the timepoint with the most severe symptoms using the PANS scale. FINDINGS Of 41 patients (37 referred and four visited upon parents' request), 23 (ten girls and 13 boys) met PANS diagnostic criteria. Mean age at PANS onset was 8·5 years (SD 3·37). 11 (48%) patients had a family history of developmental or neuropsychiatric disorders in a first-degree relative and 11 (48%) had a family history of autoimmune or inflammatory diseases in a first-degree relative. 17 (74%) patients had been previously diagnosed with a developmental disorder (n=5) or had symptoms indicative of developmental problems (n=12). A verified or suspected infection was temporally related to PANS onset in all patients; the infection was bacterial in ten (43%) patients (eight had streptococcal infection and two an infection caused by other bacteria) and viral in 13 (57%) patients. All patients had a relapsing-remitting course of illness. The mean PANS scale symptom score was 46 (SD 3·67) and the mean impairment score was 45 (2·74). Antibiotic treatment was reported as beneficial by the parents of 12 (63%) of the 19 children who received antibiotics. INTERPRETATION Our PANS cohort had severe, acute-onset, complex neuropsychiatric symptoms, a relapsing-remitting symptom course, and possible infectious triggers. Further research into the cause of, and appropriate treatment for, PANS is warranted. FUNDING Swedish Brain Foundation.
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Affiliation(s)
- Mats Johnson
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Elisabeth Fernell
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Iulian Preda
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Lena Wallin
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Anders Fasth
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Carina Gillberg
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Abstract
A previously healthy 6-year-old boy was referred to us by his primary provider, with a history of sudden onset behavioural abnormalities including irritability, sleep disturbance and anxiety. Physical examination revealed no significant findings; further analyses were not suggestive of meningitis, encephalitis, metabolic abnormalities, toxicity or any other obvious cause. On rechecking the patient's history, an episode of throat pain 1 week prior to the symptom onset was noted. Therefore, the possibility of paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) was considered. The antistreptolysin O titre was high (1078 IU/mL), and it increased to 1194 IU/mL 4 weeks later, leading to a diagnosis of PANDAS. He was started on ampicillin and administered one dose of intravenous immunoglobulin. His abnormal behaviours subsided and he returned to a normal state within 48 hours of treatment. This report aims to provide insights into the symptomology and diagnosis of PANDAS in children.
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Affiliation(s)
| | - Athar Abdul Mujeeb
- Department of Pediatrics, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
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Thienemann M, Frankovich J. Action in the face of uncertainty? J Pediatr 2019; 204:324. [PMID: 30318368 DOI: 10.1016/j.jpeds.2018.08.014] [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] [Received: 07/17/2018] [Accepted: 08/07/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Margo Thienemann
- Department of Psychiatry and Behavioral Sciences-Child and Adolescent Psychiatry and Child Development
| | - Jennifer Frankovich
- Department of Pediatrics-Division of Allergy, Immunology, and Rheumatology Stanford University Palo Alto, California
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Gilbert DL, Mink JW, Singer HS. Reply. J Pediatr 2019; 204:324-325. [PMID: 30243541 DOI: 10.1016/j.jpeds.2018.08.016] [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: 10/28/2022]
Affiliation(s)
- Donald L Gilbert
- Pediatrics and Neurology Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
| | - Jonathan W Mink
- Frederick A. Horner, MD Endowed Professor in Pediatric Neurology, Neurology, Neuroscience, and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Harvey S Singer
- Pediatrics and Neurology Johns Hopkins Hospital Baltimore, Maryland
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Gerland G, Mogyorosi-Post A, Cafferky K, Galardini G, Granli K, Tuckey G. European advocacy organizations respond to PANS/PANDAS article. J Pediatr 2019; 204:325-326. [PMID: 30337190 DOI: 10.1016/j.jpeds.2018.09.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022]
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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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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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49
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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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Brown KD, Farmer C, Freeman GM, Spartz EJ, Farhadian B, Thienemann M, Frankovich J. Effect of Early and Prophylactic Nonsteroidal Anti-Inflammatory Drugs on Flare Duration in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Observational Study of Patients Followed by an Academic Community-Based Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic. J Child Adolesc Psychopharmacol 2017; 27:619-628. [PMID: 28696786 PMCID: PMC5749580 DOI: 10.1089/cap.2016.0193] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the sudden onset of severe obsessive-compulsive symptoms and/or eating restriction along with at least two coinciding neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. We evaluated the impact of nonsteroidal anti-inflammatory drug (NSAID) treatment on flare duration in PANS/PANDAS. METHODS Patient inclusion criteria: Patients were included if they had at least one neuropsychiatric deterioration ("flare") that met strict PANS/PANDAS research criteria and for which flare duration could be assessed. Flare inclusion criteria: Any flare that started before October 15, 2016 was included and followed until the flare resolved or until the end of our data collection (November 1, 2016). Flare exclusion criteria: Flares were excluded if they were incompletely resolved, treated with aggressive immunomodulation, or treated with NSAIDs late (>30 days of flare onset). Ninety-five patients met study inclusion criteria and collectively experienced 390 flares that met flare criteria. Data were analyzed using multilevel linear models, adjusting for demographics, disease, and treatment covariates. RESULTS NSAID use was associated with a significantly shorter flare duration. Flares not treated with NSAIDs had a mean duration of approximately 12.2 weeks (95% CI: 9.3-15.1). Flares that occurred while the child was on NSAID maintenance therapy were approximately 4 weeks shorter than flares not managed with NSAIDs (95% CI: 1.85-6.24; p < 0.0001). Flares treated with NSAIDs within 30 days of flare onset were approximately 2.6 weeks shorter than flares not managed with NSAIDs (95% CI: 0.43-4.68; p = 0.02). Flares treated prophylactically and those treated early with NSAIDs did not differ in duration (p = 0.26). Among the flares that received NSAID treatment within the first 30 days, earlier intervention was modestly associated with shorter flare durations (i.e., for each day that NSAID treatment was delayed, flare duration increased by 0.18 weeks; 95% CI: 0.03-0.33; p = 0.02), though it was not statistically significant after controlling for covariates (p = 0.06). CONCLUSION NSAIDs given prophylactically or within 30 days of flare onset may shorten neuropsychiatric symptom duration in patients with new-onset and relapsing/remitting PANS and PANDAS. A randomized placebo-control clinical trial of NSAIDs in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla D. Brown
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - G. Mark Freeman
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Ellen J. Spartz
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Child & Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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