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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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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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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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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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Cocuzza S, Maniaci A, La Mantia I, Nocera F, Caruso D, Caruso S, Iannella G, Vicini C, Privitera E, Lechien JR, Pavone P. Obsessive-Compulsive Disorder in PANS/PANDAS in Children: In Search of a Qualified Treatment-A Systematic Review and Metanalysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020155. [PMID: 35204876 PMCID: PMC8869780 DOI: 10.3390/children9020155] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/18/2022] [Indexed: 12/05/2022]
Abstract
Background: Several treatment options have been proposed for pediatric acute-onset neuropsychiatric syndrome/pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANS/PANDAS). Still, no clear therapeutic protocol has been recognized to prevent these neuropsychiatric diseases. The study aims to report on the literature evidence and different treatment strategies related to these disorders. Methods: We analyzed the last 20 years’ English language literature and performed a comprehensive review of the PANS/PANDAS treatment, including studies reporting OCD outcomes post-treatment follow-up. Results: We covered 11 articles in our systematic literature review for a total of 473 patients, of which four studies included 129 surgical subjects and seven papers with 326 medically treated patients. Pooled outcomes analysis, surgical and medical treatment reported an OCD reduction, but no statistical significance was obtained (p < 0.05 for both). Conclusions: Surgical therapy in selected patients can lead to promising results, although further evidence is needed. On the other hand, the role of medical therapy remains controversial, often due to the lack of univocal curative protocols and variable responses depending on the drug used and the timing of administration. Therefore, further investigations are necessary to clarify the most appropriate therapeutic procedure.
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Affiliation(s)
- Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Antonino Maniaci
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Ignazio La Mantia
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Francesco Nocera
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Daniela Caruso
- Unit of Clinical Pediatrics, A.O.U. “Policlinico”, P.O. “G. Rodolico”, University of Catania, 95123 Catania, Italy;
| | - Sebastiano Caruso
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Giannicola Iannella
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, 47121 Forlì, Italy; (G.I.); (C.V.)
- Department of Sensory Organs, Sapienza University of Rome, 00194 Rome, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, 47121 Forlì, Italy; (G.I.); (C.V.)
| | - Elio Privitera
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Jerome Rene Lechien
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), 7000 Mons, Belgium;
| | - Piero Pavone
- Unit of Clinical Pediatrics, A.O.U. “Policlinico”, P.O. “G. Rodolico”, University of Catania, 95123 Catania, Italy;
- Correspondence:
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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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Piras C, Pintus R, Pruna D, Dessì A, Atzori L, Fanos V. Pediatric Acute-onset Neuropsychiatric Syndrome and Mycoplasma Pneumoniae Infection: A Case Report Analysis with a Metabolomics Approach. Curr Pediatr Rev 2020; 16:183-193. [PMID: 31642785 PMCID: PMC8193809 DOI: 10.2174/1573396315666191022102925] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/26/2019] [Accepted: 10/02/2019] [Indexed: 01/27/2023]
Abstract
Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinical condition characterized by a sudden and dramatic obsessive-compulsive disorder with a suggested post-infectious immune-mediated etiology. This condition is accompanied by an extensive series of relatively serious neuropsychiatric symptoms. The diagnosis of PANS is made by "exclusion", as the individual PANS symptoms overlap with a multiplicity of psychiatric disorders with the onset in childhood. A number of researchers accumulated evidence to support the hypothesis that PANS was closely associated with a number of infections. In the last decade, metabolomics played an essential role in improving the knowledge of complex biological systems and identifying potential new biomarkers as indicators of pathological progressions or pharmacologic responses to therapy. The metabolome is considered the most predictive phenotype, capable of recognizing epigenetic differences, reflecting more closely the clinical reality at any given moment and thus providing extremely dynamic data. In the present work, the most recent hypothesis and suggested mechanisms of this condition are reviewed and the case of a 10 - year-old girl with PANS is described, before and after clarithromycin treatment. The main results of this case report are discussed from a metabolomics point of view. The alteration of several metabolic pathways concerning the microbial activity highlights the possible role of the microbiome in the development of PANS. Furthermore, different metabolic perturbations at the level of protein biosynthesis, energy and amino acid metabolisms are observed and discussed. Based on our observations, it is believed that metabolomics is a promising technology to unravel the mysteries of PANS in the near future.
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Affiliation(s)
- Cristina Piras
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Roberta Pintus
- Department of Surgical Sciences, Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari, Italy
| | - Dario Pruna
- Pediatric Neurology and Epileptology Unit, Brotzu Hospital Trust, Cagliari, Italy
| | - Angelica Dessì
- Department of Surgical Sciences, Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari, Italy
| | - Luigi Atzori
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Vassilios Fanos
- Department of Surgical Sciences, Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari, Italy
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