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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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Scorr LM, Kilic-Berkmen G, Sutcliffe DJ, Dinasarapu AR, McKay JL, Bagchi P, Powell MD, Boss JM, Cereb N, Little M, Gragert L, Hanfelt J, McKeon A, Tyor W, Jinnah HA. Exploration of potential immune mechanisms in cervical dystonia. Parkinsonism Relat Disord 2024; 122:106036. [PMID: 38462403 PMCID: PMC11162750 DOI: 10.1016/j.parkreldis.2024.106036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Although there are many possible causes for cervical dystonia (CD), a specific etiology cannot be identified in most cases. Prior studies have suggested a relationship between autoimmune disease and some cases of CD, pointing to possible immunological mechanisms. OBJECTIVE The goal was to explore the potential role of multiple different immunological mechanisms in CD. METHODS First, a broad screening test compared neuronal antibodies in controls and CD. Second, unbiased blood plasma proteomics provided a broad screen for potential biologic differences between controls and CD. Third, a multiplex immunoassay compared 37 markers associated with immunological processes in controls and CD. Fourth, relative immune cell frequencies were investigated in blood samples of controls and CD. Finally, sequencing studies investigated the association of HLA DQB1 and DRB1 alleles in controls versus CD. RESULTS Screens for anti-neuronal antibodies did not reveal any obvious abnormalities. Plasma proteomics pointed towards certain abnormalities of immune mechanisms, and the multiplex assay pointed more specifically towards abnormalities in T lymphocytes. Abnormal immune cell frequencies were identified for some CD cases, and these cases clustered together as a potential subgroup. Studies of HLA alleles indicated a possible association between CD and DRB1*15:03, which is reported to mediate the penetrance of autoimmune disorders. CONCLUSIONS Altogether, the association of CD with multiple different blood-based immune measures point to abnormalities in cell-mediated immunity that may play a pathogenic role for a subgroup of individuals with CD.
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Affiliation(s)
- Laura M Scorr
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Gamze Kilic-Berkmen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Diane J Sutcliffe
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Ashok R Dinasarapu
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - J Lucas McKay
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Department of Biomedical Infortmatics, Emory School of Medicine, Atlanta, GA, 30322, USA
| | - Pritha Bagchi
- Integrated Proteomics Core, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Michael D Powell
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Jeremy M Boss
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | | | - Marian Little
- Division of Biomedical Informatics and Genomics, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Loren Gragert
- Division of Biomedical Informatics and Genomics, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - John Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, GA, 30322, USA
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Neurology and Immunology and Department of Neurology, Mayo Clinic, Rochester Mayo Clinic, Rochester, 55902, MN, USA
| | - William Tyor
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Atlanta VA Medical Center, Decatur, GA, 30033, USA
| | - H A Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, 30322, USA.
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Leonardi L, Lorenzetti G, Carsetti R, Piano Mortari E, Guido CA, Zicari AM, Förster-Waldl E, Loffredo L, Duse M, Spalice A. Immunological characterization of an Italian PANDAS cohort. Front Pediatr 2024; 11:1216282. [PMID: 38239595 PMCID: PMC10794562 DOI: 10.3389/fped.2023.1216282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/16/2023] [Indexed: 01/22/2024] Open
Abstract
This cross-sectional study aimed to contribute to the definition of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) pathophysiology. An extensive immunological assessment has been conducted to investigate both immune defects, potentially leading to recurrent Group A β-hemolytic Streptococcus (GABHS) infections, and immune dysregulation responsible for a systemic inflammatory state. Twenty-six PANDAS patients with relapsing-remitting course of disease and 11 controls with recurrent pharyngotonsillitis were enrolled. Each subject underwent a detailed phenotypic and immunological assessment including cytokine profile. A possible correlation of immunological parameters with clinical-anamnestic data was analyzed. No inborn errors of immunity were detected in either group, using first level immunological assessments. However, a trend toward higher TNF-alpha and IL-17 levels, and lower C3 levels, was detected in the PANDAS patients compared to the control group. Maternal autoimmune diseases were described in 53.3% of PANDAS patients and neuropsychiatric symptoms other than OCD and tics were detected in 76.9% patients. ASO titer did not differ significantly between the two groups. A possible correlation between enduring inflammation (elevated serum TNF-α and IL-17) and the persistence of neuropsychiatric symptoms in PANDAS patients beyond infectious episodes needs to be addressed. Further studies with larger cohorts would be pivotal to better define the role of TNF-α and IL-17 in PANDAS pathophysiology.
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Affiliation(s)
- Lucia Leonardi
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giulia Lorenzetti
- Department of Pediatrics, University of Rome Tor Vergata, Rome, Italy
| | - Rita Carsetti
- B Cell Physiopathology Unit, Immunology Research Area, Bambino Gesù Children Hospital, Rome, Italy
| | - Eva Piano Mortari
- B Cell Physiopathology Unit, Immunology Research Area, Bambino Gesù Children Hospital, Rome, Italy
| | - Cristiana Alessia Guido
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Anna Maria Zicari
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Elisabeth Förster-Waldl
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics & Adolescent Medicine, Center for Congenital Immunodeficiencies, Medical University of Vienna, Vienna, Austria
| | - Lorenzo Loffredo
- Department of Clinical, Internal Medicine, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marzia Duse
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alberto Spalice
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
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Ilyas U, Umar Z, Lin D. Group A Beta-Hemolytic Streptococcus-Induced Tic-Like Movement Disorder in an Adult: A Case Report. Cureus 2022; 14:e28451. [PMID: 36176823 PMCID: PMC9510048 DOI: 10.7759/cureus.28451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/05/2022] Open
Abstract
A tic is a sudden, repeated, quick, and uncontrollable movement of a part of the body. Tic disorders have a multifactorial etiology, including genetic predisposition, autoimmunity, and environmental factors. Movement disorders following streptococcal infection are rare and typically present in the pediatric population. We present a unique case of a 31-year-old female admitted with involuntary movements of the upper extremities of three weeks duration. Her movements start as twitching before progressing to one hand hitting the other or hitting her face. She had a strong urge before giving in to complete the action. However, the movements were partially distractable, with considerable overlap between clinical features of organic and functional tics. After a detailed workup, including a negative magnetic resonance imaging (MRI) of the brain with and without contrast, MRI of the spine, computed tomography of the chest, abdomen, and pelvis for neoplasia, as well as blood work for autoimmunity, infections, and paraneoplastic syndrome, the serology came back strongly positive for antistreptolysin O and antideoxyribonuclease B titers. Additionally, a detailed psychiatric assessment ruled out conversion disorder leading to a diagnosis of streptococcus-induced movement disorder. After a failed inpatient trial of aripiprazole, the plan included initiating deutetrabenazine with close outpatient neurology follow-up after discharge.
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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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6
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PANS/PANDAS: Clinical Experience in IVIG Treatment and State of the Art in Rehabilitation Approaches. NEUROSCI 2020. [DOI: 10.3390/neurosci1020007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) is a condition characterized by the abrupt, dramatic onset of obsessive–compulsive disorder (OCD) or eating restriction accompanied by equally abrupt and severe comorbid neuropsychiatric symptoms. PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection) is a heterogeneous syndrome identified as post-Streptococcus pyogenes infection (β-hemolytic Streptococcus group A) complications regarding the central nervous system with specific involvement of neuropsychiatric and behavioral skills. In the first part of our study, we share our experience in the treatment of a group of extreme-grade (according to CY-BOCS severity scale) symptomatic patients with intravenous immunoglobulin (IVIG), following the most recent studies regarding the dosage of the drug. Our contribution is to share our experience made on a sample of 55 patients all in the highest level of a severity grade. In the second part of our study, we also analyze the literature on PANS/PANDAS rehabilitation therapy, since in the literature there is no discussion of union and comparison on this method. Objective: This study aims to evaluate the clinical features of the patients observed from different Italian cohorts, with the attempt at evaluating clinical response to IVIG treatment in children with an extreme severity grade of PANS/PANDAS disease. Furthermore, after having analyzed the literature, we propose rehabilitation therapy as an added value to the pharmacological treatment. Materials and Methods: A total of 55 patients with a diagnosis of PANS/PANDAS, who belonged to an extreme grade of disease, were enrolled. All patients were administered with IVIG treatment at 2 g/kg per day for two consecutive days. Results: From our study, a noticeable improvement (until complete remission) of symptoms was evident for at least one year in 47 out of 55 (85%) observed children, while 11 out of these 43 (25%) showed an evident symptoms remission in a single attempt and the remaining 32 (75%) required a second administration to notice a lasting symptomatic improvement.
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7
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Henderson TA, van Lierop MJ, McLean M, Uszler JM, Thornton JF, Siow YH, Pavel DG, Cardaci J, Cohen P. Functional Neuroimaging in Psychiatry-Aiding in Diagnosis and Guiding Treatment. What the American Psychiatric Association Does Not Know. Front Psychiatry 2020; 11:276. [PMID: 32351416 PMCID: PMC7176045 DOI: 10.3389/fpsyt.2020.00276] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/23/2020] [Indexed: 12/12/2022] Open
Abstract
While early efforts in psychiatry were focused on uncovering the neurobiological basis of psychiatric symptoms, they made little progress due to limited ability to observe the living brain. Today, we know a great deal about the workings of the brain; yet, none of this neurobiological awareness has translated into the practice of psychiatry. The categorical system which dominates psychiatric diagnosis and thinking fails to match up to the real world of genetics, sophisticated psychological testing, and neuroimaging. Nevertheless, the American Psychiatric Association (APA) recently published a position paper stating that neuroimaging provided no benefit to the diagnosis and treatment of psychiatric disorders. Using the diagnosis of depression as a model, we illustrate how setting aside the unrealistic expectation of a pathognomonic "fingerprint" for categorical diagnoses, we can avoid missing the biological and, therefore, treatable contributors to psychopathology which can and are visualized using functional neuroimaging. Infection, toxicity, inflammation, gut-brain dysregulation, and traumatic brain injury can all induce psychiatric manifestations which masquerade as depression and other psychiatric disorders. We review these and provide illustrative clinical examples. We further describe situations for which single photon emission computed tomography (SPECT) and positron emission tomography (PET) functional neuroimaging already meet or exceed the criteria set forth by the APA to define a neuroimaging biomarker, including the differential diagnosis of Alzheimer's disease and other dementias, the differential diagnosis of ADHD, and the evaluation of traumatic brain injury. The limitations, both real and perceived, of SPECT and PET functional neuroimaging in the field of psychiatry are also elaborated. An important overarching concept for diagnostic imaging in all its forms, including functional neuroimaging, is that imaging allows a clinician to eliminate possibilities, narrow the differential diagnosis, and tailor the treatment plan. This progression is central to any medical diagnostic process.
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Affiliation(s)
- Theodore A Henderson
- The Synaptic Space, Inc., Denver, CO, United States.,Neuro-Luminance, Inc., Denver, CO, United States.,Dr. Theodore Henderson, Inc., Denver, CO, United States.,International Society of Applied Neuroimaging, Denver, CO, United States
| | - Muriel J van Lierop
- International Society of Applied Neuroimaging, Denver, CO, United States.,Private Practice, Toronto, ON, Canada
| | - Mary McLean
- International Society of Applied Neuroimaging, Denver, CO, United States.,Private Practice, Toronto, ON, Canada
| | - John Michael Uszler
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Providence St. John's Health Center, Santa Monica, CA, United States.,Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, United States
| | - John F Thornton
- International Society of Applied Neuroimaging, Denver, CO, United States.,Rossiter-Thornton Associates, Toronto, ON, Canada
| | - Yin-Hui Siow
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Dan G Pavel
- International Society of Applied Neuroimaging, Denver, CO, United States.,PathFinder Brain SPECT, Deerfield, IL, United States
| | - Joe Cardaci
- International Society of Applied Neuroimaging, Denver, CO, United States.,Fremantle-School of Medicine, University of Notre Dame, Fremantle, WA, Australia.,Diagnostic Nuclear Medicine, Hollywood Private Hospital, Nedlands, WA, Australia.,Consultant Physician, Perth, WA, Australia
| | - Phil Cohen
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Lions Gate Hospital, Vancouver, BC, Canada.,Radiology, University of British Columbia, Vancouver, BC, Canada
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8
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Karacaoğlan G, Lüleyap Ü, Tahiroğlu AY, Pazarcı P, Yaman A, Çetiner S, Sertdemir Y, Lüleyap D. Streptokok enfeksiyonu ile ilişkili pediatrik otoimmün nöropsikiyatrik hastalık (PANDAS) ile insan lököksit antijen (HLA) ilişkisi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.426378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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9
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Abstract
BACKGROUND The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) hypothesis suggests an association between group A beta-hemolytic streptococcus (GABHS) infections and subsequent onset or exacerbation of neuropsychiatric symptoms, such as obsessive-compulsive disorder or tic disorders. METHODS We performed a systematic review and meta-analysis including longitudinal, prospective studies on exacerbations of neuropsychiatric symptoms associated with GABHS infections in children with PANDAS. We searched PubMed and EMBASE through August 14, 2017. Two independent reviewers extracted data and we used random-effects analysis to calculate rate ratios (RR). RESULTS Three studies were included with a total of 82 PANDAS cases and 127 control children with obsessive-compulsive disorder or chronic tic disorder. PANDAS cases had a nonsignificantly increased RR of 2.33 [95% confidence interval [CI]: 0.63-8.70, P = 0.21, I = 28.3%] for exacerbations of neuropsychiatric symptoms in temporal proximity to a GABHS infection and no increased risk of GABHS infections (RR = 0.99, 95% CI: 0.56-1.73, P = 0.97, I = 45%) compared with the control children. However, PANDAS cases had an increased risk of neuropsychiatric exacerbations in general with a RR of 1.54 (95% CI: 1.12-2.11, P = 0.008, I = 0%) compared with the control children. The studies had methodologic heterogeneity, high risk of selection bias and differed concerning case definition and infection measures. CONCLUSIONS Our findings did not show significant evidence concerning higher rates of temporally associated GABHS infections and exacerbations of neuropsychiatric symptoms in children with PANDAS. The included studies were small and limited by low GABHS rates and exacerbations. Future studies with large population sizes and routine evaluations are needed to thoroughly examine the PANDAS hypothesis.
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Kentab A. PANDAS versus Hashimoto's encephalopathy: a diagnostic dilemma in a Saudi girl. Sudan J Paediatr 2019; 19:149-155. [DOI: 10.24911/sjp.106-1555859744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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11
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Çelik GG, Taş DA, Tahiroglu AY, Erken E, Seydaoğlu G, Ray PÇ, Avci A. Mannose-Binding Lectin 2 Gene Polymorphism in PANDAS Patients. ACTA ACUST UNITED AC 2018; 56:99-105. [PMID: 31223240 DOI: 10.29399/npa.22811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 04/02/2018] [Indexed: 12/16/2022]
Abstract
Introduction Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), a subgroup of obsessive-compulsive disorder (OCD), has received much attention even though the specific underlying mechanisms remain unknown. Mannose-binding lectin (MBL) is a key factor in the innate immune response. The aim of this study was to investigate the role of MBL2 gene polymorphisms in pediatric OCD patients diagnosed as PANDAS, PANDAS-Variant and non-PANDAS. Methods The study included 102 pediatric OCD patients (59 [57.8% ] PANDAS, 20 [19.6% ] non-PANDAS, and 23 [22.5% ] PANDAS-Variant) and 60 healthy controls. Polymorphisms at codon 52, 54 and 57 of the MBL2 gene were investigated. Results Codon 54 polymorphism and any variant of MBL2 gene were significantly more frequent in the OCD group than in the control group (OR=2.97, 95% CI: 1.26-6.97; and OR=2.66, 95% CI: 1.32-5.38, respectively). According to regression analysis, the presence of any variant of MBL2 gene was found in 14.50-fold increased frequency in the PANDAS subgroup compared with the non-PANDAS subgroup (95% CI: 2.49-84.19). Conclusions Our findings support an association between MBL2 genotypes and pediatric OCD, particularly PANDAS-OCD.
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Affiliation(s)
- Gonca Gül Çelik
- Department of Child Psychiatry, Çukurova University School of Medicine, Adana, Turkey
| | - Didem Arslan Taş
- Department of Internal Medicine, Rheumatology-Immunology, Çukurova University School of Medicine, Adana, Turkey
| | | | - Eren Erken
- Department of Internal Medicine, Rheumatology-Immunology, Çukurova University School of Medicine, Adana, Turkey
| | - Gülşah Seydaoğlu
- Department of Biostatistics, Çukurova University School of Medicine, Adana, Turkey
| | - Perihan Çam Ray
- Department of Child Psychiatry, Çukurova University School of Medicine, Adana, Turkey
| | - Ayşe Avci
- Department of Child Psychiatry, Çukurova University School of Medicine, Adana, Turkey
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12
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McNitt DH, Choi SJ, Keene DR, Van De Water L, Squeglia F, Berisio R, Lukomski S. Surface-exposed loops and an acidic patch in the Scl1 protein of group A Streptococcus enable Scl1 binding to wound-associated fibronectin. J Biol Chem 2018; 293:7796-7810. [PMID: 29615492 DOI: 10.1074/jbc.ra118.002250] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/29/2018] [Indexed: 12/22/2022] Open
Abstract
Keratinized epidermis constitutes a powerful barrier of the mucosa and skin, effectively preventing bacterial invasion, unless it is wounded and no longer protective. Wound healing involves deposition of distinct extracellular matrix (ECM) proteins enriched in cellular fibronectin (cFn) isoforms containing extra domain A (EDA). The streptococcal collagen-like protein 1 (Scl1) is a surface adhesin of group A Streptococcus (GAS), which contains an N-terminal variable (V) domain and a C-terminally located collagen-like domain. During wound infection, Scl1 selectively binds EDA/cFn isoforms and laminin, as well as low-density lipoprotein (LDL), through its V domain. The trimeric V domain has a six-helical bundle fold composed of three pairs of anti-parallel α-helices interconnected by hypervariable loops, but the roles of these structures in EDA/cFn binding are unclear. Here, using recombinant Scl (rScl) constructs to investigate structure-function determinants of the Scl1-EDA/cFn interaction, we found that full-length rScl1, containing both the globular V and the collagen domains, is necessary for EDA/cFn binding. We established that the surface-exposed loops, interconnecting conserved α-helices, guide recognition and binding of Scl1-V to EDA and binding to laminin and LDL. Moreover, electrostatic surface potential models of the Scl1-V domains pointed to a conserved, negatively charged pocket, surrounded by positively charged and neutral regions, as a determining factor for the binding. In light of these findings, we propose an updated model of EDA/cFn recognition by the Scl1 adhesin from GAS, representing a significant step in understanding the Scl1-ECM interactions within the wound microenvironment that underlie GAS pathogenesis.
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Affiliation(s)
- Dudley H McNitt
- From the Department of Microbiology, Immunology, and Cell Biology, West Virginia University School of Medicine, Morgantown, West Virginia 26506
| | - Soo Jeon Choi
- From the Department of Microbiology, Immunology, and Cell Biology, West Virginia University School of Medicine, Morgantown, West Virginia 26506
| | - Douglas R Keene
- the Micro-imaging Center, Shriners Hospital for Children, Portland, Oregon 97239
| | - Livingston Van De Water
- the Departments of Surgery and Regenerative and Cancer Cell Biology, Albany Medical College, Albany, New York 12208, and
| | - Flavia Squeglia
- the Institute of Biostructures and Bioimaging, Italian National Research Council, Via Mezzocannone 16, I-80134 Naples, Italy
| | - Rita Berisio
- the Institute of Biostructures and Bioimaging, Italian National Research Council, Via Mezzocannone 16, I-80134 Naples, Italy
| | - Slawomir Lukomski
- From the Department of Microbiology, Immunology, and Cell Biology, West Virginia University School of Medicine, Morgantown, West Virginia 26506,
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Orlovska S, Vestergaard CH, Bech BH, Nordentoft M, Vestergaard M, Benros ME. Association of Streptococcal Throat Infection With Mental Disorders: Testing Key Aspects of the PANDAS Hypothesis in a Nationwide Study. JAMA Psychiatry 2017; 74:740-746. [PMID: 28538981 PMCID: PMC5710247 DOI: 10.1001/jamapsychiatry.2017.0995] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Streptococcal infection has been linked with the development of obsessive-compulsive disorder (OCD) and tic disorders, a concept termed pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). However, previous studies of this association have been small, and the results have been conflicting. OBJECTIVE To investigate the risk of mental disorders, specifically OCD and tic disorders, after a streptococcal throat infection. DESIGN, SETTING, AND PARTICIPANTS A population-based cohort study was conducted using data from the nationwide Danish registers from January 1, 1996, to December 31, 2013, with up to 17 years of follow-up. The Danish National Health Service Register provided information on individuals with the registration of a streptococcal test. Data analysis was conducted from January 1, 2016, to February 28, 2017. MAIN OUTCOMES AND MEASURES Individuals were followed up in the nationwide Psychiatric Central Register for a diagnosis of any mental disorder, OCD, or tic disorders. Incidence rate ratios (IRRs) were calculated by Poisson regression analysis. RESULTS Of the 1 067 743 children (<18 years of age) included in the study (519 821 girls and 547 922 boys), 638 265 received a streptococcal test, 349 982 of whom had positive test results at least once. Individuals with a positive streptococcal test result had an increased risk of any mental disorder (n = 15 408; IRR, 1.18; 95% CI, 1.15-1.21; P < .001), particularly of OCD (n = 556; IRR, 1.51; 95% CI, 1.28-1.77; P < .001) and tic disorders (n = 993; IRR, 1.35; 95% CI, 1.21-1.50; P < .001), compared with individuals without a streptococcal test. Furthermore, the risk of any mental disorder and OCD was more elevated after a streptococcal throat infection than after a nonstreptococcal infection. Nonetheless, individuals with a nonstreptococcal throat infection also had an increased risk of any mental disorder (n = 11 315; IRR, 1.08; 95% CI, 1.06-1.11; P < .001), OCD (n = 316; IRR, 1.28; 95% CI, 1.07-1.53; P = .006), and tic disorders (n = 662; IRR, 1.25; 95% CI, 1.12-1.41; P < .001). CONCLUSIONS AND RELEVANCE This large-scale study investigating key aspects of the PANDAS hypothesis found that individuals with a streptococcal throat infection had elevated risks of mental disorders, particularly OCD and tic disorders. However, nonstreptococcal throat infection was also associated with increased risks, although less than streptococcal infections for OCD and any mental disorder, which could also support important elements of the diagnostic concept of pediatric acute-onset neuropsychiatric syndrome.
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Affiliation(s)
- Sonja Orlovska
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark,iPSYCH–The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark
| | - Claus Høstrup Vestergaard
- Department of Public Health, Research Unit and Section for General Practice, Aarhus University, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Research Unit and Section for General Practice, Aarhus University, Aarhus, Denmark,Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
| | - Merete Nordentoft
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark,iPSYCH–The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark
| | - Mogens Vestergaard
- Department of Public Health, Research Unit and Section for General Practice, Aarhus University, Aarhus, Denmark
| | - Michael Eriksen Benros
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark,iPSYCH–The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark
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Abstract
Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system, human immunodeficiency virus infection, and AIDS.
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Affiliation(s)
- Sahil Munjal
- Department of Psychiatry, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Stephen J Ferrando
- Department of Psychiatry, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA.
| | - Zachary Freyberg
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA; Department of Cell Biology, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
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15
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De Bruijn MAAM, Titulaer MJ. Anti-NMDAR encephalitis and other glutamate and GABA receptor antibody encephalopathies. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:199-217. [PMID: 27112679 DOI: 10.1016/b978-0-444-63432-0.00012-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Over the last few year, antibodies to various central nervous system receptors, particularly the glutamate and γ-aminobutyric acid (GABA) receptors, have been found to be associated with autoimmune neurologic disorders. The receptors include the N-methyl-d-aspartate receptor (NMDAR), the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), the metabotropic glutamate receptors (mGluRs), and GABA type A and B receptors (respectively GABAAR and GABABR). Compared to the previously described paraneoplastic antibodies directed at intracellular targets, the patients with receptor antibodies are often younger, they less frequently have malignancies, and they respond better to immunotherapy. Many of the patients have limbic encephalitis with amnesia, disorientation, seizures, and psychological or psychiatric symptoms, but those with NMDAR antibodies usually develop a more widespread form of encephalitis, often leading to a decrease in consciousness and requirement for long-term intensive care treatment. The autoantibodies bind directly to the synaptic or extrasynaptic receptors on the membrane surface, and have direct effects on signal transduction in central synapses. These conditions are very important to recognize as the symptoms and complications can be fatal when not treated in time, whereas with immunotherapy many patients recover considerably.
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Affiliation(s)
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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16
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Cunningham MW, Cox CJ. Autoimmunity against dopamine receptors in neuropsychiatric and movement disorders: a review of Sydenham chorea and beyond. Acta Physiol (Oxf) 2016; 216:90-100. [PMID: 26454143 PMCID: PMC5812018 DOI: 10.1111/apha.12614] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 02/26/2015] [Accepted: 09/23/2015] [Indexed: 12/16/2022]
Abstract
Antineuronal autoantibodies are associated with the involuntary movement disorder Sydenham chorea (SC) and paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) which are characterized by the acute onset of tics and/or obsessive compulsive disorder (OCD). In SC and PANDAS, autoantibodies signal human neuronal cells and activate calcium calmodulin-dependent protein kinase II (CaMKII). Animal models immunized with group A streptococcal antigens demonstrate autoantibodies against dopamine receptors and concomitantly altered behaviours. Human monoclonal antibodies (mAbs) derived from SC target and signal the dopamine D2L (long) receptor (D2R). Antibodies against D2R were elevated over normal levels in SC and acute-onset PANDAS with small choreiform movements, but were not elevated over normal levels in PANDAS-like chronic tics and OCD. The expression of human SC-derived anti-D2R autoantibody V gene in B cells and serum of transgenic mice demonstrated that the human autoantibody targets dopaminergic neurones in the basal ganglia and other types of neurones in the cortex. Here, we review current evidence supporting the hypothesis that antineuronal antibodies, specifically against dopamine receptors, follow streptococcal exposures and may target dopamine receptors and alter central dopamine pathways leading to movement and neuropsychiatric disorders.
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Affiliation(s)
- M W Cunningham
- Department of Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - C J Cox
- Department of Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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17
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Mullen S. Review of pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.07.184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
During the past decade, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) has become the topic of numerous debates, sparking research on its presentation, existence, and treatment. As the awareness of PANDAS has increased among the general community, health care providers have been forced to increase their knowledge of this controversial disease state. This article will review the background information, diagnostic criteria, treatment, and contentious issues related to PANDAS.
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Affiliation(s)
- Sandy Mullen
- (Corresponding author) Clinical Pharmacist, Psychiatry, Clinical Assistant Professor, Pharmacy, Clinical Assistant Professor, Psychiatry, Virginia Commonwealth University Health System, Richmond, Virginia,
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18
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Li E, Ruan Y, Chen Q, Cui X, Lv L, Zheng P, Wang L. Streptococcal infection and immune response in children with Tourette's syndrome. Childs Nerv Syst 2015; 31:1157-63. [PMID: 25930720 DOI: 10.1007/s00381-015-2692-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 11/04/2014] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Erzhen Li
- Neurology Department, Capital Institute of Pediatrics, Beijing, 100020, China,
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19
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Walker KG, de Vries PJ, Stein DJ, Wilmshurst JM. Sydenham Chorea and PANDAS in South Africa: Review of Evidence and Recommendations for Management in Resource-Poor Countries. J Child Neurol 2015; 30:850-9. [PMID: 25227516 DOI: 10.1177/0883073814544704] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/28/2014] [Indexed: 11/15/2022]
Abstract
In South Africa, and worldwide, rheumatic fever represents a public health problem. Improved diagnosis and management of Sydenham chorea, a major manifestation of acute rheumatic fever is key to prevention of rheumatic heart disease. This article reviews Sydenham chorea from its original description to current opinions. Recommendations are founded on expert opinion as class 1 data is lacking. This South African perspective is relevant to resource-poor settings globally insofar as it provides diagnosis and management recommendations for primary- and secondary-level healthcare professionals who care for patients in such environments. Four basic tenets of care are recommended, namely, elimination of the streptococcal infection, symptomatic treatment, immunological treatment, and nonpharmacologic interventions. A user-friendly outcome measurement tool, viable for use in low-resource settings is presented. Introduction of this tool may lead to increased awareness of the neuropsychiatric manifestations of poststreptococcal movement disorders in Africa, where reports are limited.
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Affiliation(s)
- Kathleen G Walker
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa Rheumatic Fever Clinic, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Petrus J de Vries
- Division of Child & Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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20
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Peila E, Mortara P, Cicerale A, Pinessi L. Paroxysmal non-kinesigenic dyskinesia, post-streptococcal syndromes and psychogenic movement disorders: a diagnostic challenge. CASE REPORTS 2015; 2015:bcr-2014-207449. [DOI: 10.1136/bcr-2014-207449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Cox CJ, Zuccolo AJ, Edwards EV, Mascaro-Blanco A, Alvarez K, Stoner J, Chang K, Cunningham MW. Antineuronal antibodies in a heterogeneous group of youth and young adults with tics and obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2015; 25:76-85. [PMID: 25658702 PMCID: PMC4340634 DOI: 10.1089/cap.2014.0048] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Antineuronal antibodies have been implicated in tic and obsessive compulsive disorders (OCD) associated with group A streptococcal infections. We investigated antineuronal autoantibody levels as well as antibody-mediated neuronal cell signaling activity, as previously reported for Sydenham chorea and pediatric autoimmune neuropsychiatric disorder associated with streptococci (PANDAS), to determine immunological profiles for a large cohort of children with tics and/or OCD. METHODS Study participants (n=311; ages 4-27 years, 66% male) were selected from a larger group of individuals with self-reported neuropsychiatric symptoms (n=742) and included only those with accurate knowledge of group A streptococcal infection status, except for four individuals in whom streptococcal infection status was unknown. Healthy control samples (n=16; ages 5-14 years, 81% male), came from the National Institute of Mental Health and Yale University. In addition to serum donations, participants and/or legal guardians provided neuropsychiatric and related medical histories of symptoms that had lasted >1 year. Antineuronal immunoglobulin G (IgG) titers were measured by standard enzyme-linked immunosorbent assay (ELISA) and compared with mean titers of normal age-matched sera against lysoganglioside, tubulin, and dopamine receptors (D1R and D2R). Antibody-mediated signaling of calcium calmodulin dependent protein kinase II (CaMKII) activity in a human neuronal cell line (SK-N-SH) was tested in serum. RESULTS Of 311 individuals, 222 (71%) had evidence of group A streptococcal infection, which was associated with tics and/or OCD status (p=0.0087). Sera from individuals with tics and/or OCD (n=261) had evidence of elevated serum IgG antibodies against human D1R (p<0.0001) and lysoganglioside (p=0.0001), and higher serum activation of CaMKII activity (p<0.0001) in a human neuronal cell line compared with healthy controls (n=16). Furthermore, patients with tics and OCD had significantly increased activation of CaMKII activity compared with patients with only tics or only OCD (p<0.033 for each). CONCLUSION Our study suggested a significant correlation of streptococcal-associated tics and OCD with elevated anti-D1R and antilysoganglioside antineuronal antibodies in serum concomitant with higher activation of CaMKII in human neuronal cells. Youth and young adults with chronic tics and OCD may have underlying infectious/immunologic etiology.
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Affiliation(s)
- Carol J. Cox
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amir J. Zuccolo
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Erica V. Edwards
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Adita Mascaro-Blanco
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kathy Alvarez
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Julie Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kiki Chang
- Department of Psychiatry and Behavioral Sciences, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, California
| | - Madeleine W. Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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22
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Pavone P, Rapisarda V, Serra A, Nicita F, Spalice A, Parano E, Rizzo R, Maiolino L, Di Mauro P, Vitaliti G, Coco A, Falsaperla R, Trifiletti RR, Cocuzza S. Pediatric autoimmune neuropsychiatric disorder associated with group a streptococcal infection: the role of surgical treatment. Int J Immunopathol Pharmacol 2014; 27:371-8. [PMID: 25280028 DOI: 10.1177/039463201402700307] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) is a well-defined syndrome in which tics (motor and/or vocal) and/or obsessive compulsive disorders (OCD) consistently exacerbate in temporal correlation to a Group A beta-haemolytic streptococcal infection. In children with PANDAS, there is speculation about whether tonsillectomy or adenotonsillectomy might improve the neuropsychiatric course. Our objective was to examine whether such surgery impacted remission or, in patients without remission, modified clinical course of the disease, streptococcal antibody titers, neuronal antibodies or clinical severity of Obsessive-Compulsive Disorder (OCD) and/or tics. Study participants (n = 120) with positive PANDAS criteria were recruited, examined, and divided into surgical or non-surgery groups. The surgical group consisted of children with tonsillectomy or adenotonsillectomy (n=56). The remaining children were categorized as non-surgery (n=64). Clinical follow-up was made every 2 months for more than 2 years. Surgery did not affect symptomatology progression, streptococcal and neuronal antibodies, or the clinical severity of neuropsychiatric symptoms in these children. In conclusion, in our series clinical progression, antibody production, and neuropsychiatric symptom severity did not differ on the basis of surgical status. We cannot uphold surgical management as likely to impact positive remission rates, course of OCD/tics, or antibody concentrations in children with PANDAS.
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Affiliation(s)
- P Pavone
- U.O. of Pediatrics and Pediatrics Emergency, Azienda Ospedaliera Universitaria, Policlinico Vittorio Emanuele, Catania, Italy
| | - V Rapisarda
- Occupational Medicine, Vittorio Emanuele, Policlinico Hospital, University of Catania, Catania, Italy
| | - A Serra
- Department of Medical Surgical Specialties, ENT Clinic, University of Catania, Italy
| | - F Nicita
- Department of Pediatrics, Child Neurology Division, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - A Spalice
- Department of Pediatrics, Child Neurology Division, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - E Parano
- ISBN, The National Research Council of Italy, CNR, Catania, Italy
| | - R Rizzo
- Child Neuropsychiatric Division, Department of Pediatrics, AUO OVE, Policlinico, University of Catania , Catania, Italy
| | - L Maiolino
- Department of Medical Surgical Specialties, ENT Clinic, University of Catania, Italy
| | - P Di Mauro
- Department of Medical Surgical Specialties, ENT Clinic, University of Catania, Italy
| | - G Vitaliti
- U.O. of Pediatrics and Pediatrics Emergency, Azienda Ospedaliera Universitaria, Policlinico Vittorio Emanuele, Catania, Italy
| | - A Coco
- U.O. of Pediatrics and Pediatrics Emergency, Azienda Ospedaliera Universitaria, Policlinico Vittorio Emanuele, Catania, Italy
| | - R Falsaperla
- U.O. of Pediatrics and Pediatrics Emergency, Azienda Ospedaliera Universitaria, Policlinico Vittorio Emanuele, Catania, Italy
| | | | - S Cocuzza
- Department of Medical Surgical Specialties, ENT Clinic, University of Catania, Italy
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23
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Navkhare P, Kalra G. The curious case of the "inseparable child". Indian J Psychiatry 2014; 56:292-4. [PMID: 25316942 PMCID: PMC4181186 DOI: 10.4103/0019-5545.140650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Streptococcal infections in children rarely lead to neuropsychiatric manifestations referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. The common sequelae include tics, Tourette's syndrome or obsessive-compulsive disorder. Rare presentations may include separation anxiety disorder, body dysmorphic disorder and attention deficit hyperactivity disorder. We present a case of a 10-year-old child that presented primarily with abrupt onset of separation anxiety without any other neuropsychiatric manifestations such as tics or obsessive-compulsive symptoms. Streptococcal infections may present with varied neuropsychiatric manifestations in the pediatric age group and one needs to be more vigilant in cases that have an abrupt onset and unusual presentation. A high index of suspicion is important to diagnose such cases and provide them with a timely treatment.
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24
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Esposito S, Bianchini S, Baggi E, Fattizzo M, Rigante D. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: an overview. Eur J Clin Microbiol Infect Dis 2014; 33:2105-9. [PMID: 24953744 DOI: 10.1007/s10096-014-2185-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/09/2014] [Indexed: 11/28/2022]
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25
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Vitaliti G, Trifiletti RR, Falsaperla R, Parano E, Spalice A, Pavone P. A new clinical feature associated with familial early-onset of dystonic-guttural tics: An unusual diagnosis of PANDAS. J Pediatr Neurosci 2014; 9:79-81. [PMID: 24891915 PMCID: PMC4040045 DOI: 10.4103/1817-1745.131497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Until today there is a large debate about the existence of PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) or PANS (pediatric acute onset neuropsychiatric syndrome). These children usually have dramatic, "overnight" onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also have comorbid features of associated disorders. Herein, we report a family with an early onset of tics, with exclusively dystonic and guttural tics. All patients had a particularly strong excitement trigger. Two of the patients were shown to have signs suggestive of PANDAS and all family members were Group A beta-hemolytic Streptococcus (GABHS) carriers. The PANDAS spectrum is probably a group of disorders. We have described a PANDAS variant, in which the family seems to share common autoimmune pattern and may be viewed in the large spectrum of PANDAS.
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Affiliation(s)
- Giovanna Vitaliti
- Department of Pediatric and Pediatric Emergency, AUO OVE-Policlinico, University of Catania, Italy
| | - Rosario R Trifiletti
- Department of Pediatrics, Morristown Memorial Hospital, Morristown, New Jersey, USA
| | - Raffaele Falsaperla
- Department of Pediatric and Pediatric Emergency, AUO OVE-Policlinico, University of Catania, Italy
| | - Enrico Parano
- Department of Pediatrics, Morristown Memorial Hospital, Morristown, New Jersey, USA ; Institute of Neurological Science, The National Research Council of Italy, CNR, Catania, Italy
| | - Alberto Spalice
- Department of Paediatrics, Division of Child Neurology, University of Rome La Sapienza, Italy
| | - Piero Pavone
- Department of Pediatrics, Morristown Memorial Hospital, Morristown, New Jersey, USA
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26
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Filleron A, Marchandin H, Rodière M, Jeziorski E. Complications in the subacute phase of invasive Streptococcus pyogenes infections in pediatrics: two case reports and review of the literature. Clin Pediatr (Phila) 2014; 53:191-3. [PMID: 23460650 DOI: 10.1177/0009922813479164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Anne Filleron
- 1Centre Hospitalier Régional Universitaire de Montpellier, Hôpital Lapeyronie, Montpellier, France
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27
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Feigenson KA, Kusnecov AW, Silverstein SM. Inflammation and the two-hit hypothesis of schizophrenia. Neurosci Biobehav Rev 2014; 38:72-93. [PMID: 24247023 PMCID: PMC3896922 DOI: 10.1016/j.neubiorev.2013.11.006] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/26/2013] [Accepted: 11/07/2013] [Indexed: 12/12/2022]
Abstract
The high societal and individual cost of schizophrenia necessitates finding better, more effective treatment, diagnosis, and prevention strategies. One of the obstacles in this endeavor is the diverse set of etiologies that comprises schizophrenia. A substantial body of evidence has grown over the last few decades to suggest that schizophrenia is a heterogeneous syndrome with overlapping symptoms and etiologies. At the same time, an increasing number of clinical, epidemiological, and experimental studies have shown links between schizophrenia and inflammatory conditions. In this review, we analyze the literature on inflammation and schizophrenia, with a particular focus on comorbidity, biomarkers, and environmental insults. We then identify several mechanisms by which inflammation could influence the development of schizophrenia via the two-hit hypothesis. Lastly, we note the relevance of these findings to clinical applications in the diagnosis, prevention, and treatment of schizophrenia.
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Affiliation(s)
- Keith A Feigenson
- Robert Wood Johnson Medical School at Rutgers, The State University of New Jersey, 675 Hoes Lane, Piscataway, NJ 08854, USA.
| | - Alex W Kusnecov
- Department of Psychology, Behavioral and Systems Neuroscience Program and Joint Graduate Program in Toxicology, Rutgers University, 52 Frelinghuysen Road, Piscataway, NJ 08854-8020, USA.
| | - Steven M Silverstein
- Robert Wood Johnson Medical School at Rutgers, The State University of New Jersey, 675 Hoes Lane, Piscataway, NJ 08854, USA; University Behavioral Health Care at Rutgers, The State University of New Jersey, 671 Hoes Lane, Piscataway, NJ 08855, USA.
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Cooper MS, Clark VP. Neuroinflammation, neuroautoimmunity, and the co-morbidities of complex regional pain syndrome. J Neuroimmune Pharmacol 2013; 8:452-69. [PMID: 22923151 PMCID: PMC3661922 DOI: 10.1007/s11481-012-9392-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 07/23/2012] [Indexed: 02/07/2023]
Abstract
Complex Regional Pain Syndrome (CRPS) is associated with non-dermatomal patterns of pain, unusual movement disorders, and somatovisceral dysfunctions. These symptoms are viewed by some neurologists and psychiatrists as being psychogenic in origin. Recent evidence, however, suggests that an autoimmune attack on self-antigens found in the peripheral and central nervous system may underlie a number of CRPS symptoms. From both animal and human studies, evidence is accumulating that neuroinflammation can spread, either anterograde or retrograde, via axonal projections in the CNS, thereby establishing neuroinflammatory tracks and secondary neuroinflammatory foci within the neuraxis. These findings suggest that neuroinflammatory lesions, as well as their associated functional consequences, should be evaluated during the differential diagnosis of non-dermatomal pain presentations, atypical movement disorders, as well as other "medically unexplained symptoms", which are often attributed to psychogenic illness.
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Affiliation(s)
- Mark S Cooper
- Department of Biology, University of Washington, Seattle, WA 98195-1800, USA.
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Carter CJ. Toxoplasmosis and Polygenic Disease Susceptibility Genes: Extensive Toxoplasma gondii Host/Pathogen Interactome Enrichment in Nine Psychiatric or Neurological Disorders. J Pathog 2013; 2013:965046. [PMID: 23533776 PMCID: PMC3603208 DOI: 10.1155/2013/965046] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 08/18/2012] [Accepted: 09/10/2012] [Indexed: 01/04/2023] Open
Abstract
Toxoplasma gondii is not only implicated in schizophrenia and related disorders, but also in Alzheimer's or Parkinson's disease, cancer, cardiac myopathies, and autoimmune disorders. During its life cycle, the pathogen interacts with ~3000 host genes or proteins. Susceptibility genes for multiple sclerosis, Alzheimer's disease, schizophrenia, bipolar disorder, depression, childhood obesity, Parkinson's disease, attention deficit hyperactivity disorder (P from 8.01E - 05 (ADHD) to 1.22E - 71) (multiple sclerosis), and autism (P = 0.013), but not anorexia or chronic fatigue are highly enriched in the human arm of this interactome and 18 (ADHD) to 33% (MS) of the susceptibility genes relate to it. The signalling pathways involved in the susceptibility gene/interactome overlaps are relatively specific and relevant to each disease suggesting a means whereby susceptibility genes could orient the attentions of a single pathogen towards disruption of the specific pathways that together contribute (positively or negatively) to the endophenotypes of different diseases. Conditional protein knockdown, orchestrated by T. gondii proteins or antibodies binding to those of the host (pathogen derived autoimmunity) and metabolite exchange, may contribute to this disruption. Susceptibility genes may thus be related to the causes and influencers of disease, rather than (and as well as) to the disease itself.
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Affiliation(s)
- C. J. Carter
- Polygenic Pathways, Flat 2, 40 Baldslow Road, Hastings, East Sussex TN34 2EY, UK
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Brumback RA. "3 . . 2 . . 1 . . Impact [factor]: target [academic career] destroyed!": just another statistical casualty. J Child Neurol 2012. [PMID: 23183597 DOI: 10.1177/0883073812465014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
"Publish or perish" is the time-honored "principle" for academicians who race to accumulate lines under the "publications" section of a curriculum vitae. The original intent of publication-to inform others of findings and further scientific knowledge-has been corrupted by factors including (1) exponential growth of journals and the journal industry, fueled in part by intrusion of the Internet into all aspects of academic life; and (2) adoption of journal metrics (rather than written content) as the measure of scientific quality. The proprietary Thomson Reuters Impact Factor is the most pernicious metric, having caused editors and publishers to change editorial practices to boost the number. At the same time, gullible administrators and government agencies have been persuaded that metrics for the journal in which materials are published can be used as a measure of the worth of individual investigators (and institutions) and their research efforts: simple numbers can be substituted for the burdensome effort required to read and assess research quality. Thus, granting of research funds, awarding of academic rank and tenure, and determination of salaries (including bonus payments) have become tied to manipulable journal metrics rather than the significance or quality of reported research. Therefore, it is no wonder that the integrity of science is more often being questioned. How should a young investigator approach the "publish or perish" dilemma? Performing sound research and preparing optimal materials for publication must remain the overriding goals: properly articulate the question addressed by the study; thoroughly document all methods and case information; carefully describe results including any conflicting or negative findings; discuss the importance of the findings along with how the results address the initial question and whether findings refute or confirm previous studies; prepare properly cited bibliographic references; list all author contributions, potential conflicts of interest, financial support, and required ethical approvals; and provide a catchy title and an abstract containing sufficient information that other investigators perusing scientific indices will be enticed to read the published article. Submit the completed manuscript to the most appropriate journal based on that journal's previously published content and relevance to the field of study regardless of journal metrics. On publication, notify investigators in the same field to ask for their comments on the work. Thus, an individual will become known for the quality of his or her work product and the worshiping of publication metrics will be unnecessary.
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Jadhav S, Coffey BJ. Drug-induced movement disorders and Syndenham's chorea in an antipsychotic-treated young child. J Child Adolesc Psychopharmacol 2011; 21:487-90. [PMID: 22040195 DOI: 10.1089/cap.2011.2157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sneha Jadhav
- Child and Adolescent Psychiatry Department, Kansas University Medical Center, Kansas City, Kansas, USA
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Brilot F, Merheb V, Ding A, Murphy T, Dale RC. Antibody binding to neuronal surface in Sydenham chorea, but not in PANDAS or Tourette syndrome. Neurology 2011; 76:1508-13. [PMID: 21411742 DOI: 10.1212/wnl.0b013e3182181090] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To test the hypothesis that Sydenham chorea (SC) immunoglobulin G (IgG) autoantibodies bind to specific neuronal surface proteins, whereas IgG from patients with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) or Tourette syndrome (TS) do not bind to neuronal surface proteins. METHODS We used live differentiated SH-SY5Y cells, which have neuronal and dopaminergic characteristics. Using flow cytometry, we measured serum IgG cell surface binding in patients with SC (n = 11), PANDAS (n = 12), and TS (n = 11), and compared the findings to healthy controls (n = 11) and other neurologic controls (n = 11). In order to determine the specificity of binding to neuronal antigens, we also used a non-neuronal cell line, HEK 293. RESULTS The mean IgG cell surface binding was significantly higher in the SC group compared to all other groups (p < 0.001). By contrast, there was no difference between the PANDAS or TS groups and the controls. Using the non-neuronal HEK-293 cells, there was no significant difference in IgG cell surface binding between any groups. CONCLUSIONS Serum autoantibodies that bind to neuronal cell surface antigens are present in SC, but not in PANDAS or TS. These findings strengthen the hypothesis that SC is due to a pathogenic autoantibody, but weaken the autoantibody hypothesis in PANDAS and TS.
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Affiliation(s)
- F Brilot
- Neuroimmunology Group, Institute for Neurosciences and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Australia.
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Dmitriev AV, Chaussee MS. The Streptococcus pyogenes proteome: maps, virulence factors and vaccine candidates. Future Microbiol 2011; 5:1539-51. [PMID: 21073313 DOI: 10.2217/fmb.10.116] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Streptococcus pyogenes is an important cause of human morbidity and mortality worldwide. A wealth of genomic information related to this pathogen has facilitated exploration of the proteome, particularly in response to environmental conditions thought to mimic various aspects of pathogenesis. Proteomic approaches are also used to identify immunoreactive proteins for vaccine development and to identify proteins that may induce autoimmunity. These studies have revealed new mechanisms involved in regulating the S. pyogenes proteome, which has opened up new avenues in the study of S. pyogenes pathogenesis. This article describes the methods used, and progress being made towards characterizing the S. pyogenes proteome, including studies seeking to identify potential vaccine candidates.
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Affiliation(s)
- Alexander V Dmitriev
- Department of Molecular Microbiology, Institute of Experimental Medicine. acad. Pavlov str., 12, Saint-Petersburg, 197376, Russia
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Oosterveer DM, Overweg-Plandsoen WCT, Roos RAC. Sydenham's chorea: a practical overview of the current literature. Pediatr Neurol 2010; 43:1-6. [PMID: 20682195 DOI: 10.1016/j.pediatrneurol.2009.11.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 11/24/2009] [Accepted: 11/25/2009] [Indexed: 10/19/2022]
Abstract
Sydenham's chorea is characterized by uncoordinated movements, emotional instability, and hypotonia. It can occur up to several months after group A beta-hemolytic Streptococcus infection. A diagnosis of Sydenham's chorea in a patient with acute chorea involves an application of the Jones criteria and the exclusion of other causes of chorea. In patients with an atypical history or hemichorea, cranial magnetic resonance imaging is indicated to exclude other cerebral pathologies. A pathogenesis has not been elucidated, and therapy has not been investigated in placebo-controlled trials. Antibiotic treatment and a 2-week or 3-week schedule of antibiotic prophylaxis are recommended. If the chorea is severe, valproate or carbamazepine can be effective. In more severely affected patients, dopamine receptor blocking agents or corticosteroids can be used.
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Passive transfer of streptococcus-induced antibodies reproduces behavioral disturbances in a mouse model of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection. Mol Psychiatry 2010; 15:712-26. [PMID: 19668249 DOI: 10.1038/mp.2009.77] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Streptococcal infections can induce obsessive-compulsive and tic disorders. In children, this syndrome, frequently associated with disturbances in attention, learning and mood, has been designated pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Autoantibodies recognizing central nervous system (CNS) epitopes are found in sera of most PANDAS subjects, but may not be unique to this neuropsychiatric subset. In support of a humoral immune mechanism, clinical improvement often follows plasmapheresis or intravenous immunoglobulin. We recently described a PANDAS mouse model wherein repetitive behaviors correlate with peripheral anti-CNS antibodies and immune deposits in brain following streptococcal immunization. These antibodies are directed against group A beta-hemolytic streptococcus matrix (M) protein and cross-react with molecular targets complement C4 protein and alpha-2-macroglobulin in brain. Here we show additional deficits in motor coordination, learning/memory and social interaction in PANDAS mice, replicating more complex aspects of human disease. Furthermore, we demonstrate for the first time that humoral immunity is necessary and sufficient to induce the syndrome through experiments wherein naive mice are transfused with immunoglobulin G (IgG) from PANDAS mice. Depletion of IgG from donor sera abrogates behavior changes. These functional disturbances link to the autoimmunity-related IgG1 subclass but are not attributable to differences in cytokine profiles. The mode of disrupting blood-brain barrier integrity differentially affects the ultimate CNS distribution of these antibodies and is shown to be an additional important determinant of neuropsychiatric outcomes. This work provides insights into PANDAS pathogenesis and may lead to new strategies for identification and treatment of children at risk for autoimmune brain disorders.
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Hsieh MY, Lee WI, Lin KL, Hung PC, Chou ML, Chang MY, Huang JL, Wang HS. Immunologic analysis and serum heavy metal levels in exacerbated Tourette syndrome. Pediatr Allergy Immunol 2010; 21:e764-71. [PMID: 20337969 DOI: 10.1111/j.1399-3038.2010.01009.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tourette syndrome (TS) is a childhood-onset and relapsing disorder characterized by involuntary simple or complex tics and high co-morbidity with behavioral anomalies. Its pathophysiologic mechanisms remain unclarified. We investigated immunologic alternations and serum heavy metal levels in patients with TS to elucidate the unclarified mechanisms. Based on the Yale Global Tic Severity Scale, fifteen TS subjects (four females) aged 8-34 (mean: 15.4 +/- 6.7) in exacerbation with mean severity score 40.3 +/- 14.6 were enrolled in this study. The immunoglobulin levels were normal except for higher immunoglobulin E levels (in 10 patients) with atopy. In exacerbation, there were reverse CD4/CD8 (in two), higher percentages of natural killer cells (in five) and memory T cells (in eight), diminished lymphocyte activation CD69 marker (in three) and impaired NK cytotoxicity (in six) that showed a trend of lower inhibitory CD94 (NKG2A), activating NKp46, and perforin expression compared to those of patients with stable TS and healthy controls, but similar granzyme expression. Serum ASLO, mycoplasma antibody and the levels of heavy metals were not significantly different. All aforementioned immune alterations returned to the normal ranges except for the consistently higher memory T cells. Our study demonstrated that, in some patients with TS, consistently higher memory T cells and lower cytotoxicity in exacerbation status reflect immune alterations and underscore the potential for immunomodulation or immunosuppressive treatment.
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Affiliation(s)
- Meng-Ying Hsieh
- Graduate Institute of Medical Clinics, Chang Gung University Collage of Medicine and Children's Hospital, Linkou, Taiwan
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Barking vocalizations and shaking movements in a 13-year old girl. J Dev Behav Pediatr 2010; 31:S11-3. [PMID: 20414060 DOI: 10.1097/dbp.0b013e3181d83030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Erica is a 13-year old female who was hospitalized for a 4-week history of "barking" noises and 2 weeks of generalized shaking episodes. Four weeks prior to admission, she had a viral upper respiratory infection (URI) with cough which was treated with over-the-counter cough syrup. After resolution of the URI, she developed a persistent cough that turned into a "bark"-like vocalization. Both the mother and patient demonstrated the bark as an "arf" sound like that of a small dog at times, a large dog at others. These vocalizations were unrelenting, occurring 3-10 times per minute only while awake. They were not precipitated by any known factors nor were there alleviating factors. She could not voluntarily suppress the sound. In addition to the vocalizations, episodes of generalized shaking of the extremities began 2 weeks prior to admission. According to Erica's mother, each episode lasted about 10-60 seconds and occurred 30-40 times a day only when she was awake. These episodes were not rhythmic or symmetric, and they were not associated with bowel or bladder incontinence. There was no alteration of consciousness following the episodes. Erica denied any recollection of the barking or shaking. The medical evaluation did not reveal an etiology. It included a complete physical examination, a neurological examination, biochemical laboratory studies, and a negative video EEG study that captured 10 episodes of shaking. Child psychiatry was consulted. Erica was a pleasant, quiet female with slightly constricted affect and a normal speech pattern. She reported that she was a straight-A honors student who had difficulty trusting others; she said that she had no friends, only "associates." She said that she had periods of feeling "sad" and crying easily, but could not identify any recent stressful event. Episodes of barking and shaking diminished during the hospitalization. Erica was discharged home with outpatient psychiatric follow-up.
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Cabo López I, García Ruiz Espiga P, Herranz Bárcenas A, Bustamante de Garnica I. PANDAS: adult variant. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Cabo López I, García Ruiz Espiga P, Herranz Bárcenas A, Bustamante de Garnica I. PANDAS, variante del adulto. Neurologia 2010. [DOI: 10.1016/s0213-4853(10)70026-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Garcia-Lopez R, Perea-Milla E, Garcia CR, Rivas-Ruiz F, Romero-Gonzalez J, Moreno JL, Faus V, Aguas GDC, Diaz JCR. New therapeutic approach to Tourette Syndrome in children based on a randomized placebo-controlled double-blind phase IV study of the effectiveness and safety of magnesium and vitamin B6. Trials 2009; 10:16. [PMID: 19284553 PMCID: PMC2660319 DOI: 10.1186/1745-6215-10-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 03/10/2009] [Indexed: 11/26/2022] Open
Abstract
Background Tourette Syndrome (TS) is a neurological condition presenting chronic motor and phonic tics, and important degree of comorbidity. Considered an uncommon illness, it first becomes apparent during childhood. Current standard treatment only achieves partial control of the condition, and provokes frequent, and sometimes severe, side effects. Methods and design Main aim: To show that, with respect to placebo treatment, the combination of 0.5 mEq/Kg magnesium and 2 mg/Kg vitamin B6 reduces motor and phonic tics and incapacity in cases of exacerbated TS among children aged 7–14 years, as measured on the Yale Global Tic Severity Scale (YGTSS). Secondary aims: Assess the safety of the treatment. Describe metabolic changes revealed by PET. Measure the impact of the experimental treatment on family life. Methodology Randomized, blinded clinical trials. Phase IV study (new proposal for treatment with magnesium and vitamin B6). Scope: children in the geographic area of the study group. Recruitment of subjects: to include patients diagnosed with TS, in accordance with DSM-IV criteria (307.23), during a period of exacerbation, and provided none of the exclusion criteria are met. Instrumentation: clinical data and the YGTSS score will be obtained at the outset of a period of exacerbation (t0). The examinations will be made after 15 (t1), 30 (t2), 60 (t3) and 90 days (t4). PET will be performed at the t0 and t4. We evaluated decrease in the overall score (t0, t1, t2, t3, t4), PET variations, and impact made by the treatment on the patient's life (Psychological General Well-Being Index). Discussion Few clinical trials have been carried out on children with TS, but they are necessary, as current treatment possibilities are insufficient and often provoke side effects. The difficulty of dealing with an uncommon illness makes designing such a study all the more complicated. The present study seeks to overcome possible methodological problems by implementing a prior, phase II study, in order to calculate the relevant statistical parameters and to determine the safety of the proposed treatment. Providing a collateral treatment with magnesium and vitamin B6 could improve control of the illness and help reduce side effects. This protocol was approved by the Andalusian Government Committee for Clinical Trials (Spain). This study was funded by the Health Department of the Andalusian Regional Government and by the Healthcare Research Fund of the Carlos III Healthcare Institute (Spanish Ministry of Health). Trial Registration Current Controlled Trials ISRCTN41082378
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Affiliation(s)
- Rafael Garcia-Lopez
- Department of Anaesthesia and Reanimation, Hospital Costa del Sol, Ctra Nacional 340, km 187, 29603 Marbella, Spain.
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Abstract
Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system.
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Batuecas Caletrío Á, Sánchez González F, Cruz Ruiz SS, Santos Gorjón P, Blanco Pérez P. Síndrome PANDAS. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2008. [DOI: 10.1016/s0001-6519(08)75557-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Singer HS, Gause C, Morris C, Lopez P. Serial immune markers do not correlate with clinical exacerbations in pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Pediatrics 2008; 121:1198-205. [PMID: 18519490 DOI: 10.1542/peds.2007-2658] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections is hypothesized to be a poststreptococcal autoimmune disorder. If clinical exacerbations are triggered by a streptococcal infection that activates cross-reacting antibodies against neuronal tissue or alters the production of cytokines, then a longitudinal analysis would be expected to identify a correlation between clinical symptoms and a change in autoimmune markers. PATIENTS AND METHODS Serial serum samples were available on 12 children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections participating in a prospective blinded study: 2 samples before an exacerbation point, 1 during the clinical exacerbation, and 2 after the exacerbation. Six subjects had a well-defined clinical exacerbation in association with a documented streptococcal infection, and 6 had a clinical exacerbation without an associated streptococcal infection. All of the serum samples were assayed for antibodies against human postmortem caudate, putamen, and prefrontal cortex; commercially prepared antigens; and complex sugars. Cytokines were measured by 2 different methodologies. RESULTS No correlation was identified between clinical exacerbations and autoimmune markers, including: enzyme-linked immunosorbent assay measures of antineuronal antibodies; Western immunoblotting with emphasis on brain region proteins located at 40, 45, and 60 kDa or their corresponding identified antigens; competitive inhibition enzyme-linked immunosorbent assay to evaluate lysoganglioside G(M1) antibodies; and measures of inflammatory cytokines. No differences were identified between individuals with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections with or without exacerbations triggered by streptococcal infections. CONCLUSIONS The failure of immune markers to correlate with clinical exacerbations in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections raises serious concerns about the viability of autoimmunity as a pathophysiological mechanism in this disorder.
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Affiliation(s)
- Harvey S Singer
- Division of Pediatric Neurology, Johns Hopkins Hospital, Rubenstein Child Health Building, Suite 2158, 200 N Wolfe St, Baltimore, MD 21287, USA.
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Abstract
Erica is a 13-year old female who was hospitalized for a 4-week history of "barking" noises and 2 weeks of generalized shaking episodes. Four weeks prior to admission, she had a viral upper respiratory infection (URI) with cough which was treated with over-the-counter cough syrup. After resolution of the URI, she developed a persistent cough that turned into a "bark"-like vocalization. Both the mother and patient demonstrated the bark as an "arf" sound like that of a small dog at times, a large dog at others. These vocalizations were unrelenting, occurring 3-10 times per minute only while awake. They were not precipitated by any known factors nor were there alleviating factors. She could not voluntarily suppress the sound. In addition to the vocalizations, episodes of generalized shaking of the extremities began 2 weeks prior to admission. According to Erica's mother, each episode lasted about 10-60 seconds and occurred 30-40 times a day only when she was awake. These episodes were not rhythmic or symmetric, and they were not associated with bowel or bladder incontinence. There was no alteration of consciousness following the episodes. Erica denied any recollection of the barking or shaking.The medical evaluation did not reveal an etiology. It included a complete physical examination, a neurological examination, biochemical laboratory studies, and a negative video EEG study that captured 10 episodes of shaking. Child psychiatry was consulted. Erica was a pleasant, quiet female with slightly constricted affect and a normal speech pattern. She reported that she was a straight-A honors student who had difficulty trusting others; she said that she had no friends, only "associates." She said that she had periods of feeling "sad" and crying easily, but could not identify any recent stressful event. Episodes of barking and shaking diminished during the hospitalization. Erica was discharged home with outpatient psychiatric follow-up.
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Abstract
Tourette syndrome and obsessive-compulsive disorder are neuropsychiatric disorders that have sparked considerable interest over the decades. They are the focus of research for a remarkable diversity of disciplines, ranging from neuroimagers and prenatal epidemiologists to experts in the neural circuits that connect the cortex with the basal ganglia, as well as neuroimmunologists focusing on brain-based autoimmune phenomena. Several hypotheses have been put forward to explain the onset and exacerbation of these illnesses. Here, we discuss the clinical phenomenology and treatment options that are currently available. New psychopharmacological agents are being used that are based on a greater understanding of the neurobiology and are being used in combination with behavioral interventions. Longitudinal clinical investigations into clinical symptoms and the natural course are providing additional clues on the underlying pathophysiology. Recent advances in research models are also reviewed in an attempt to clarify some of the molecular etiologies that lead to these disorders.
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Affiliation(s)
- Paul J Lombroso
- Child Study Center, Yale University School of Medicine, New Haven, CT 06520, United States.
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Batuecas Caletrío Á, Sánchez González F, Cruz Ruiz SS, Santos Gorjón P, Blanco Pérez P. PANDAS Syndrome: ANew Tonsillectomy Indication? ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s2173-5735(08)70254-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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