1
|
Prasad N, Johng S, Powell D, Williams M, Latimer E, Harley E. Role of tonsillectomy and adenoidectomy in parental satisfaction of treatments for PANDAS. Am J Otolaryngol 2021; 42:102963. [PMID: 33706120 DOI: 10.1016/j.amjoto.2021.102963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/14/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To examine caregiver satisfaction with treatments for pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) and how symptom frequency changes over time. METHODS A list was created for PANDAS subjects seen at the Georgetown Pediatric Otolaryngology clinic from 2015 to 2018. Questionnaires were distributed to caregivers able to be contacted; 62% responded (n = 60). Subjects were placed in groups based on treatments reported: tonsillectomy and adenoidectomy (T&A, n = 28), T&A and intravenous immunoglobulin (IVIG, n = 22), or nonsurgical treatment(s) (n = 10). Caregivers reported frequencies for each of 10 associated symptoms from time of treatment to 12 months and also expressed their satisfaction with treatment. RESULTS Patients were treated with antibiotics (n = 60, 100%), T&A (83.3%), IVIG (40%), Rituximab (15%), steroids (20%), and/or plasma exchange (10%). Caregivers for 66% (n = 33) of surgical patients identified T&A as the most effective treatment, and 80% would choose the operation again. No difference in median caregiver satisfaction level was found among the groups (n = 0.196). There was no significant difference in frequency for any of the symptoms (all p > 0.05) except choreiform movement (p = 0.0296). CONCLUSION Caregivers reported a decreasing frequency of symptoms over time regardless of treatment and had no difference in satisfaction. T&A was the most preferred treatment and the most impactful on symptoms for surgical patients. Given the challenges of immunologic therapies, T&A in combination with antibiotics should be considered as an early intervention for PANDAS.
Collapse
|
4
|
Frankovich J, Swedo S, Murphy T, Dale RC, Agalliu D, Williams K, Daines M, Hornig M, Chugani H, Sanger T, Muscal E, Pasternack M, Cooperstock M, Gans H, Zhang Y, Cunningham M, Bernstein G, Bromberg R, Willett T, Brown K, Farhadian B, Chang K, Geller D, Hernandez J, Sherr J, Shaw R, Latimer E, Leckman J, Thienemann M, PANS/PANDAS Consortium. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II-Use of Immunomodulatory Therapies. J Child Adolesc Psychopharmacol 2017; 27:574-593. [PMID: 36358107 PMCID: PMC9836706 DOI: 10.1089/cap.2016.0148] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinically heterogeneous disorder with a number of different etiologies and disease mechanisms. Inflammatory and postinfectious autoimmune presentations of PANS occur frequently, with some clinical series documenting immune abnormalities in 75%-80% of patients. Thus, comprehensive treatment protocols must include immunological interventions, but their use should be reserved only for PANS cases in which the symptoms represent underlying neuroinflammation or postinfectious autoimmunity, as seen in the PANDAS subgroup (Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections). Methods: The PANS Research Consortium (PRC) immunomodulatory task force is comprised of immunologists, rheumatologists, neurologists, infectious disease experts, general pediatricians, psychiatrists, nurse practitioners, and basic scientists with expertise in neuroimmunology and PANS-related animal models. Preliminary treatment guidelines were created in the Spring of 2014 at the National Institute of Health and refined over the ensuing 2 years over conference calls and a shared web-based document. Seven pediatric mental health practitioners, with expertise in diagnosing and monitoring patients with PANS, were consulted to create categories in disease severity and critically review final recommendations. All authors played a role in creating these guidelines. The views of all authors were incorporated and all authors gave final approval of these guidelines. Results: Separate guidelines were created for the use of immunomodulatory therapies in PANS patients with (1) mild, (2) moderate-to-severe, and (3) extreme/life-threatening severity. For mildly impairing PANS, the most appropriate therapy may be "tincture of time" combined with cognitive behavioral therapy and other supportive therapies. If symptoms persist, nonsteroidal anti-inflammatory drugs and/or short oral corticosteroid bursts are recommended. For moderate-to-severe PANS, oral or intravenous corticosteroids may be sufficient. However, intravenous immunoglobulin (IVIG) is often the preferred treatment for these patients by most PRC members. For more severe or chronic presentations, prolonged corticosteroid courses (with taper) or repeated high-dose corticosteroids may be indicated. For PANS with extreme and life-threatening impairment, therapeutic plasma exchange is the first-line therapy given either alone or in combination with IVIG, high-dose intravenous corticosteroids, and/or rituximab. Conclusions: These recommendations will help guide the use of anti-inflammatory and immunomodulatory therapy in the treatment of PANS.
Collapse
Affiliation(s)
- Jennifer Frankovich
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Tanya Murphy
- Rothman Center for Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Russell C. Dale
- Paediatrics and Child Health, Institute for Neuroscience and Muscle Research, the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Dritan Agalliu
- Pathology and Cell Biology (in Neurology and Pharmacology), Columbia University, New York, New York
| | - Kyle Williams
- Pediatric Neuropsychiatry and Immunology Program in the OCD and Related Disorders Program, Harvard Medical School, Boston, Massachusetts
| | - Michael Daines
- Allergy, Immunology, and Rheumatology, The University of Arizona College of Medicine Tuscon, Tuscon, Arizona
| | - Mady Hornig
- Epidemiology, Center for Infection and Immunity, Columbia University Medical Center, New York, New York
| | - Harry Chugani
- Pediatric Neurology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Terence Sanger
- Neurology, University of Southern California Pediatric Movement Disorders Center, Children's Hospital of Los Angeles, Los Angeles, California
| | - Eyal Muscal
- Pediatric Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Mark Pasternack
- Pediatric Infectious Disease, Harvard Medical School, Boston, Massachusetts
| | - Michael Cooperstock
- Pediatric Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Hayley Gans
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California
| | - Yujuan Zhang
- Pediatric Rheumatology, Tufts University School of Medicine, Boston, Massachusetts
| | - Madeleine Cunningham
- Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Gail Bernstein
- Child and Adolescent Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Reuven Bromberg
- Pediatric Rheumatology, Miami Rheumatology, LLC, Miami, Florida
| | - Theresa Willett
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kayla Brown
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kiki Chang
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Daniel Geller
- Pediatric OCD and Tic Disorder Program, Harvard Medical School, Boston, Massachusetts
| | - Joseph Hernandez
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Janell Sherr
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Richard Shaw
- Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Latimer
- Pediatric Neurology, Georgetown University Hospital, Washington, District of Columbia
| | - James Leckman
- Child Psychiatry, Psychiatry, Psychology and Pediatrics, Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | | |
Collapse
|
5
|
Windfuhr JP. Tonsillectomy remains a questionable option for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc07. [PMID: 28025607 PMCID: PMC5169080 DOI: 10.3205/cto000134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a disease attributed to children with obsessive compulsive disorders (OCD) or tic disorders associated with streptococcal infections. Because otolaryngologists examine a large number of pediatric patients with recurrent streptococcal infections, tonsillectomy (TE) is a common option of therapy. This study was conducted to evaluate the efficacy of TE in patients presenting with verified PANDAS. Material and methods: A PubMed review was performed using search terms "tonsillectomy" and "PANDAS", "OCD", "compulsive" "pediatric autoimmune", "chorea" and "tic" limited by publication date of January 1, 1995, to July 31, 2015. Reviews without patients were not included in the review. Results: Nine papers matched our search criteria, including 6 case reports with 8 patients and 3 case series. Most case reports were in favor of TE, but this was by far not supported by the findings in the case series. The follow-up ranged from 2 to 36 months in case reports and from 24 to 36 in case series. Conclusion: Establishing the diagnosis of PANDAS is complicated because of underlying comorbidities in the field of neurology-psychiatry and the lack of a reliable biomarker. The positive outcome after TE as reported in case studies may be influenced by the postoperative medication and is not supported by the results of large-scale studies. In the light of the considerable postoperative morbidity rate, it appears wise to indicate TE for PANDAS only in supervised clinical studies.
Collapse
Affiliation(s)
- Jochen P Windfuhr
- Department of Otolaryngology, Head & Neck Surgery, Allergology, Kliniken Maria Hilf, Mönchengladbach, Germany
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
10
|
Roessner V, Schoenefeld K, Buse J, Wanderer S, Rothenberger A. Therapie der Tic-Störungen. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2012; 40:217-36; quiz 236-7. [DOI: 10.1024/1422-4917/a000176] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Seit dem Erscheinen unserer letzten Übersichtsarbeit zur «Therapie der Tic-Störungen» in der Zeitschrift für Kinder- und Jugendpsychiatrie wurden große Fortschritte auf diesem Gebiet erzielt. So wurden einzelne Bausteine auf dem Weg zur optimalen Behandlung konkretisiert, z. B. Veröffentlichung einheitlicher Kriterien zur Behandlungsindikation oder Entwicklung und Evaluierung eines detaillierten verhaltenstherapeutischen Manuals zum Habit-Reversal-Training. Daneben sind neue Therapiemöglichkeiten, wie das Medikament Aripiprazol oder die Tiefenhirnstimulation, erfolgreich implementiert worden. Auch wurde das Augenmerk viel stärker auf begleitende Störungen, wie ADHS und Zwangsstörungen, gerichtet, da diese in der Regel eine besonders starke Beeinträchtigung für die weitere Entwicklung des Kindes oder Jugendlichen darstellen. Dennoch bestehen weiterhin große Wissenslücken über die Effektivität der einzelnen Behandlungsmethoden, möglicher Kombinationsbehandlungen sowie deren direkter Vergleich untereinander. Daneben erschwert das Fehlen jeglicher Parameter zur Vorhersage der individuell sehr unterschiedlichen Entwicklung der Tics über die nächsten Monate und Jahre eine evidenzbasierte Therapieempfehlung und damit das Erlernen der Feinheiten bei der Behandlung von Tic-Störungen. Zusammengefasst ist noch immer eine große klinische Erfahrung für die Therapieentscheidungen beim einzelnen Patienten von großem Vorteil angesichts der enormen Bandbreite an individueller Tic-Symptomatik und Komorbidität gepaart mit den unvorhersehbaren Schwankungen im zeitlichen Verlauf.
Collapse
Affiliation(s)
- Veit Roessner
- Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Dresden
| | - Katia Schoenefeld
- Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Dresden
| | - Judith Buse
- Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Dresden
| | - Sina Wanderer
- Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Dresden
| | | |
Collapse
|