D8/17 and CD19 expression on lymphocytes of patients with acute rheumatic fever and Tourette's disorder

Biomarkers and Tourette syndrome: a systematic review and meta-analysis

Objective

This research aims to investigate whether peripheral biomarkers might differentiate individuals with Tourette syndrome (TS) from those without the condition.

Methods

A broad range of databases was searched through November 2022. This study employed a systematic literature review and subsequent meta-analysis of case-control studies that assessed the aberration of biomarkers of patients with TS and controls.

Results

A total of 81 studies were identified, out of which 60 met the eligibility criteria for inclusion in the meta-analysis. Following a meticulous screening procedure to determine the feasibility of incorporating case-control studies into the meta-analysis, 13 comparisons were statistically significant [CD3+ T cell, CD4+ T cell, CD4+ T cell to CD8+ T cell ratio, NK-cell, anti-streptolysin O antibodies, anti-DNase antibodies, glutamic acid (Glu), aspartic acid (Asp), ferritin (Fe), zinc (Zn), lead (Pb), vitamin D, and brain-derived neurotrophic factor (BDNF)]. Publication bias was found for anti-streptolysin O antibodies. Suggestive associations were evidenced for norsalsolinol (NSAL), neuron-specific enolase (NSE), and S100B.

Conclusion

In this study, we present empirical evidence substantiating the link between several peripheral biomarkers and the early diagnosis of TS. Larger and more standardized studies are necessary to replicate the observed results, elucidate the specificity of the biomarkers for TS, and evaluate their precision for use in clinical settings.

Immune Abnormalities in Autism Spectrum Disorder-Could They Hold Promise for Causative Treatment?

Autism spectrum disorders (ASD) are characterized by impairments in language and communication development, social behavior, and the occurrence of stereotypic patterns of behavior and interests. Despite substantial speculation about causes of ASD, its exact etiology remains unknown. Recent studies highlight a link between immune dysfunction and behavioral traits. Various immune anomalies, including humoral and cellular immunity along with abnormalities at the molecular level, have been reported. There is evidence of altered immune function both in cerebrospinal fluid and peripheral blood. Several studies hypothesize a role for neuroinflammation in ASD and are supported by brain tissue and cerebrospinal fluid analysis, as well as evidence of microglial activation. It has been shown that immune abnormalities occur in a substantial number of individuals with ASD. Identifying subgroups with immune system dysregulation and linking specific cellular immunophenotypes to different symptoms would be key to defining a group of patients with immune abnormalities as a major etiology underlying behavioral symptoms. These determinations would provide the opportunity to investigate causative treatments for a defined patient group that may specifically benefit from such an approach. This review summarizes recent insights into immune system dysfunction in individuals with ASD and discusses the potential implications for future therapies.

[The specific pathogenetic features of the development of chronic tonsillar pathology]

The authors discuss the mechanisms underlying the development of chronic tonsillar pathology confirmed by the methods of histological, autoradiographic, and bacteriological diagnostics. The new aspects of vital activity of microorganisms in the parenchymal tissue of the palatine tonsils are highlighted that account for the low effectiveness of the conservative therapy of chronic tonsillitis and give evidence of the necessity of the surgical treatment of this condition.

Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression

OBJECTIVE

The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC).

METHODS

Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement.

RESULTS

During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6±0.48g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1.

CONCLUSION

The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis.

Streptococcal infection and immune response in children with Tourette's syndrome

BACKGROUND

Streptococcal infection and basal ganglia inflammation are hypothesized to be involved in Tourette's syndrome (TS). There is a need for effective therapies for managing TS. We studied streptococcal infection and immunity in TS following immunomodulator (pidotimod) therapy.

METHODS

Blood samples from 58 patients with TS and 128 age-matched healthy controls enabled measurement of antistreptolysin O (ASO), T cells, natural killer (NK) cells, interleukin-6 (IL-6) and interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α). Forty-four patients with abnormal T cell numbers were divided into two groups and treated with pidotimod granules (pidotimod group, n = 20) or pidotimod plus dopaminergic receptor antagonists (combination group, n = 24). Yale Global Tic Severity Scale (YGTSS) scores and immunologic indices were assessed after treatment.

RESULTS

An ASO >1:200 was found in 22.4% of children with TS, 7.5% of controls, and 38.9% of children with both TS and attention deficit hyperactivity disorder (ADHD) compared to 15.0% of children with TS alone (P < 0.05). Children with TS showed decreased CD3(+) and CD4(+) T cells, CD4(+)/CD8(+) ratio, IL-6 and IL-8, increased NKC and TNF-α (P < 0.05) as compared to controls. ASO-positive children with TS had lower CD4(+) T cells as compared to ASO-negative children with TS, and lower IL-6 and IL-8 levels as compared to controls (P < 0.05). After 8 weeks of pidotimod treatment, IL-8 was increased compared to either tiapride hydrochloride or haloperidol and pidotimod (P < 0.05).

CONCLUSIONS

Streptococcal infection in TS patients is associated with immune and cytokine dysfunction, which can be potentially managed with immunomodulator therapy.

Immune-mediated animal models of Tourette syndrome

An autoimmune diathesis has been proposed in Tourette syndrome (TS) and related neuropsychiatric disorders such as obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism and anorexia nervosa. Environmental triggers including infection and xenobiotics are hypothesized to lead to the production of brain-directed autoantibodies in a subset of genetically susceptible individuals. Although much work has focused on Group A Streptococcus (GAS), the role of this common childhood infection remains controversial. Animal model studies based on immune and autoantibody findings in TS have demonstrated immunoglobulin (Ig) deposits and stereotypic movements and related behavioral disturbances reminiscent of TS following exposure to GAS, other activators of host anti-microbial responses, soluble immune mediators and anti-GAS or anti-neuronal antibodies. Demonstration of the ability to recreate these abnormalities through passive transfer of serum IgG from GAS-immunized mice into naïve mice and abrogation of this activity through depletion of IgG has provided compelling evidence in support of the autoimmune hypothesis. Immunologically-based animal models of TS are a potent tool for dissecting the pathogenesis of this serious neuropsychiatric syndrome.

Normalisation of immune cell imbalance after pharmacological treatments of patients suffering from obsessive-compulsive disorder

Recent data have shown the presence of immunological alterations in adult patients suffering from obsessive-compulsive disorder (OCD). The objective of this study was to examine the possible effects of 12 months of treatment with different serotonergic drugs, such as clomipramine and selective serotonin reuptake inhibitors (SSRIs) on peripheral immunological cells of 18 OCD patients. Both the absolute number and percent of CD4+, CD8+, CD3+, CD19+ and CD56+ cells were measured in peripheral blood before and after treatment by means of a Facstar Flow Sorter apparatus. At baseline, all patients showed a significant increase of CD8+ and decrease of CD4+ lymphocytes when compared with a similar group of healthy control subjects; after the treatment, CD8+ and CD4+ cells, respectively, decreased and increased significantly, and the CD4+/CD8+ ratio increased, when compared with baseline values, in parallel with the clinical improvement. These data suggest that the alterations of immune cells reported in patients with OCD at baseline may be reverted by treatment with SRIs and should be considered a state-dependent marker, perhaps related to a condition of stress.

Dopaminergic receptor D5 mRNA expression is increased in circulating lymphocytes of Tourette syndrome patients

Tourette syndrome (TS) is a neuropsychiatric disorder in which dopaminergic dysfunction and immune system abnormalities seem to coexist. Using real-time PCR, we determined mRNA expression of dopamine receptors (DRs) D1-5 in peripheral blood lymphocytes (PBLs) from 15 TS patients and 15 sex- and age-matched healthy controls (HCs). DRD5 mRNA levels in cells from TS were higher than in cells from HCs. In TS patients with obsessive-compulsive disorder, DRD5 mRNA levels in PBLs showed a highly positive correlation with the severity of compulsive symptoms. DRD5 mRNA upregulation in PBLs from TS patients may represent a peripheral marker of dopaminergic dysfunction and supports the involvement of the immune system in TS.

What every psychiatrist should know about PANDAS: a review

The term Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS) was coined by Swedo et al. in 1998 to describe a subset of childhood obsessive-compulsive disorders (OCD) and tic disorders triggered by group-A beta-hemolytic Streptococcus pyogenes infection. Like adult OCD, PANDAS is associated with basal ganglia dysfunction. Other putative pathogenetic mechanisms of PANDAS include molecular mimicry and autoimmune-mediated altered neuronal signaling, involving calcium-calmodulin dependent protein (CaM) kinase II activity. Nonetheless the contrasting results from numerous studies provide no consensus on whether PANDAS should be considered as a specific nosological entity or simply a useful research framework. Herein we discuss available data that could provide insight into pathophysiology of adult OCD, or might explain cases of treatment-resistance. We also review the latest research findings on diagnostic and treatment.

Chain reaction or time bomb: a neuropsychiatric-developmental/neurodevelopmental formulation of tourettisms, pervasive developmental disorder, and schizophreniform symptomatology associated with PANDAS

We present the case of a boy who over time sequentially exhibited symptoms consistent with a pervasive developmental disorder, schizophreniform symptomatology, multiple motor and vocal tics, and myoclonus. During this period he experienced multiple episodes of group A beta-haemolytic streptococcal (strep) infection confirmed by culture and serological studies. We speculate that paediatric autoimmune neuropsychiatric disorder associated with strep (PANDAS) may have served as an element in a complex chain of causation influencing the expression of his symptoms. Our main emphasis is to utilize our case study as an example of the application in case formulation of the neuropsychiatric developmental model and of the neurodevelopmental model on symptom ontogenesis and clinical outcome.

Autoimmune neuropsychiatric disorders associated with streptococcal infection: Sydenham chorea, PANDAS, and PANDAS variants

Streptococcal infection in children is usually benign and self-limited. In a small percentage of children, prominent neurologic and/or psychiatric sequelae can occur. Sydenham chorea is the best defined and best recognized. PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) is a well-defined syndrome in which tics (motor and/or vocal) and/or obsessive-compulsive disorder consistently exacerbate in temporal correlation to a group A beta-hemolytic streptococcal infection. PANDAS constitutes a subset of children with tics, Tourette syndrome, and obsessive-compulsive disorder. In addition to strictly defined PANDAS, we and others have recognized several PANDAS variants, including adult-onset variant, a dystonic variant, a myoclonic variant, and a "chronic" PANDAS variant. The nosology and classification of these entities are rapidly evolving. The recognition that some pediatric neurobehavioral syndromes have infectious and/or immunologic triggers points to important new avenues of disease treatment. In this review, we summarize this complex and rapidly evolving area of clinical research.

B-cell antigen D8/17 is a marker of rheumatic fever susceptibility in Aboriginal Australians and can be tested in remote settings

OBJECTIVE

To test the B-cell antigen D8/17 as a marker of past rheumatic fever (RF) in a predominantly Aboriginal Australian population, and to evaluate technical modifications to allow its use in remote settings.

DESIGN AND SETTING

Cross-sectional survey in a remote Aboriginal community, a regional tertiary referral hospital and a tertiary paediatric centre in Melbourne.

PARTICIPANTS

106 people, including three with acute RF, 38 with a history of past RF, 20 relatives of these people, and 45 healthy controls.

MAIN OUTCOME MEASURE

D8/17 expression in B cells.

RESULTS

Blood was collected from each participant and the expression of D8/17 and CD19 in each sample was analysed by flow cytometry. The mean proportion of D8/17-positive B cells was 39.3% (SD, 11.8) in patients with previous RF, 22.5% (SD, 5.2) in first-degree relatives, 11.6% (SD, 7.2) in controls, and 83.7% (SD, 10.1) in patients with acute RF (analysis of variance test between means, P = 0.001). A cut-off of 22.1% of D8/17-positive B cells to indicate past RF yielded the highest percentage of correct results (95.4%). Delayed staining of whole blood (mean, 0.55 days; SD, 0.2) gave equivalent results to immediate staining, but the D8/17 assay on peripheral blood mononuclear cells was unreliable.

CONCLUSIONS

The B-cell antigen D8/17 accurately identifies Australians with a past history of RF, and the assay is feasible in remote settings with access to facilities capable of performing D8/17 staining within half a day of sample collection.

Immunology of obsessive-compulsive disorder

Childhood OCD often develops into a chronic illness that lasts decades. Proof that some type of immunotherapy (such as antibiotic prophylaxis) could significantly reduce recurrence or exacerbation of symptoms of OC or tics would suggest a supportive role for immune triggers in the onset or worsening of these conditions and provide additional tools for improving outcome. The validity of PANDAS will continue to be questioned, however,because demonstrating a clear causation will be difficult on a background ofa common childhood illness. Along with the previously mentioned immuno-therapy study, validation of the PANDAS phenotype (broadly interpreted)would be advanced from new and continued research in the following areas: (1) prospective studies to identify infectious triggers in the onset and exacerbations of OCD spectrum disorders, (2) biological measures for immune and genetic susceptibility, and (3) large scale epidemiological studies demonstrating the relationship between infection and OCD spectrum disorders. The assimilation of these study results should allow for elucidation of the immune system's role in the onset and maintenance of OCD.

Group A streptococcal infections of the skin: molecular advances but limited therapeutic progress

PURPOSE OF REVIEW

With the sequencing of several Streptococcus pyogenes (group A Streptococcus) genomes have come major advances in understanding the pathogenesis of group A Streptococcus-associated diseases. This review focuses on group A Streptococcus skin infections and summarizes data published in the English language medical literature in 2004 and 2005.

RECENT FINDINGS

Group A Streptococcus shows enormous and evolving molecular diversity driven by horizontal transmission between group A Streptococcus strains and between group A Streptococcus and other streptococci. Acquisition of prophages accounts for much of the diversity, conferring both virulence through phage-associated virulence factors and increased bacterial survival against host defences. Studies of group A Streptococcus isolates outside the US also question the generalizability of classic group A Streptococcus M serotype associations with specific disease entities such as acute rheumatic fever and necrotizing fasciitis. The distinction between throat and skin group A Streptococcus has become blurred. Although there have been few advances in treatment of group A Streptococcus skin infections, developments towards group A Streptococcus vaccines are promising.

SUMMARY

The diversity of group A Streptococcus remains a challenge for vaccine development. As acute rheumatic fever and streptococcal pyoderma occur predominantly in disadvantaged populations, international funding support will be necessary for any group A Streptococcus vaccine to have a sustained impact on the global burden of disease.

Tic disorders and obsessive-compulsive disorder: is autoimmunity involved?

The precise cause of tic disorders and paediatric obsessive-compulsive disorder (OCD) is unknown. In addition to genetic factors, autoimmunity may play a role, possibly as a sequela of preceding streptococcal throat infections in susceptible children. Here we review the most recent findings, from July 2003 onwards, with regard to a possible relationship between tics/OCD and autoimmunity. Evidence about an intriguing correlation between streptococcal infections and tic disorders and OCD is accumulating. Specific criteria have been outlined for paediatric autoimmune disorders associated with streptococcal infections (PANDAS), but autoimmunity may also be involved in tic disorders and/or OCD in general. Anti-basal ganglia auto-antibodies are an important potential indicator of autoimmunity. Although the lack of a standardized methodology makes comparisons of findings difficult, new data has emerged pointing to the possible involvement of specific auto-antigens. Earlier findings of increased D8/17 B cell expression as a putative susceptibility marker could not be replicated, possibly due to instability of the D8/17-binding antibody. Although PANDAS patients have been reported to improve after therapeutic plasma exchange, and antibiotics may prevent symptom exacerbations, immune-based treatments should not be routinely given. In future studies, demonstrating the pathogenetic significance of anti-basal ganglia antibodies in animals is a major challenge to draw any firm conclusions about a role for autoimmunity. Future longitudinal studies should be aimed at assessing the precise relationship between symptom exacerbations, infections, and immune parameters, possibly along with gene expression profiles.

Acute rheumatic fever

Acute rheumatic fever (ARF) and its chronic sequela, rheumatic heart disease (RHD), have become rare in most affluent populations, but remain unchecked in developing countries and in some poor, mainly indigenous populations in wealthy countries. More than a century of research, mainly in North America and Europe, has improved our understanding of ARF and RHD. However, whether traditional views need to be updated in view of the epidemiological shift of the past 50 years is still to be established, and improved data from developing countries are needed. Doctors who work in populations with a high incidence of ARF are adapting existing diagnostic guidelines to increase their sensitivity. Group A streptococcal vaccines are still years away from being available and, even if the obstacles of serotype coverage and safety can be overcome, their cost could make them inaccessible to the populations that need them most. New approaches to primary prevention are needed given the limitations of primary prophylaxis as a population-based strategy. The most effective approach for control of ARF and RHD is secondary prophylaxis, which is best delivered as part of a coordinated control programme.