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Xu J, Frankovich J, Liu RJ, Thienemann M, Silverman M, Farhadian B, Willett T, Manko C, Columbo L, Leibold C, Vaccarino FM, Che A, Pittenger C. Elevated antibody binding to striatal cholinergic interneurons in patients with pediatric acute-onset neuropsychiatric syndrome. Brain Behav Immun 2024; 122:241-255. [PMID: 39084540 DOI: 10.1016/j.bbi.2024.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 06/16/2024] [Accepted: 07/28/2024] [Indexed: 08/02/2024] Open
Abstract
Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the abrupt onset of significant obsessive-compulsive symptoms (OCS) and/or severe food restriction, together with other neuropsychiatric manifestations. An autoimmune pathogenesis triggered by infection has been proposed for at least a subset of PANS. The older diagnosis of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) describes rapid onset of OCD and/or tics associated with infection with Group A Streptococcus. The pathophysiology of PANS and PANDAS remains incompletely understood. We recently found serum antibodies from children with rigorously defined PANDAS to selectively bind to cholinergic interneurons (CINs) in the striatum. Here we examine this binding in children with relapsing and remitting PANS, a more heterogeneous condition, collected in a distinct clinical context from those examined in our previous work, from children with a clinical history of Streptococcus infection. IgG from PANS cases showed elevated binding to striatal CINs in both mouse and human brain. Patient plasma collected during symptom flare decreased a molecular marker of CIN activity, phospho-riboprotein S6, in ex vivo brain slices; control plasma did not. Neither elevated antibody binding to CINs nor diminished CIN activity was seen with plasma collected from the same children during remission. These findings replicate what we have seen previously in PANDAS and support the hypothesis that at least a subset of PANS cases have a neuroimmune pathogenesis. Given the critical role of CINs in modulating basal ganglia function, these findings confirm striatal CINs as a locus of interest in the pathophysiology of both PANS and PANDAS.
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Affiliation(s)
- Jian Xu
- Departments of Psychiatry, Yale University, New Haven, CT, USA.
| | - Jennifer Frankovich
- Departments of Pediatrics, Stanford University School of Medicine, Stanford University, CA, USA; Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Rong-Jian Liu
- Departments of Psychiatry, Yale University, New Haven, CT, USA
| | - Margo Thienemann
- Departments of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, CA, USA; Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Child & Adolescent Psychiatry and Child Development, Stanford University School of Medicine, Stanford University, CA, USA
| | - Melissa Silverman
- Departments of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, CA, USA; Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Child & Adolescent Psychiatry and Child Development, Stanford University School of Medicine, Stanford University, CA, USA
| | - Bahare Farhadian
- Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Theresa Willett
- Departments of Pediatrics, Stanford University School of Medicine, Stanford University, CA, USA; Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Cindy Manko
- Departments of Pediatrics, Stanford University School of Medicine, Stanford University, CA, USA; Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Laurie Columbo
- Departments of Pediatrics, Stanford University School of Medicine, Stanford University, CA, USA; Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA; Division of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Collin Leibold
- Immune Behavioral Health Clinic and Research Program, Stanford University School of Medicine, Stanford University, CA, USA
| | - Flora M Vaccarino
- Departments of Neuroscience, Yale University, New Haven, CT, USA; Child Study Center, Yale University, New Haven, CT, USA
| | - Alicia Che
- Departments of Psychiatry, Yale University, New Haven, CT, USA; Interdepartmental Neuroscience Program, Yale University, New Haven, CT, USA; Wu-Tsai Institute, Yale University, New Haven, CT, USA; Center for Brain and Mind Health, Yale University, New Haven, CT, USA
| | - Christopher Pittenger
- Departments of Psychiatry, Yale University, New Haven, CT, USA; Departments of Psychology, Yale University, New Haven, CT, USA; Child Study Center, Yale University, New Haven, CT, USA; Interdepartmental Neuroscience Program, Yale University, New Haven, CT, USA; Wu-Tsai Institute, Yale University, New Haven, CT, USA; Center for Brain and Mind Health, Yale University, New Haven, CT, USA.
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2
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Dore S, Satta D, Zinellu A, Boscia G, Carta A, Fruschelli M, Serra R, Pinna A. Ocular Tics and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Diseases 2024; 12:83. [PMID: 38785738 PMCID: PMC11120000 DOI: 10.3390/diseases12050083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/13/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
Little is known about ocular tics in Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections (PANDAS). In this retrospective study, we examined the clinical records of children with motor tics referred to the Ophthalmology Unit, Azienda Ospedaliero-Universitaria di Sassari, Italy, in 2010-2019. The presence of ocular tics was investigated. Data about antistreptolysin O (ASO) and anti-DNase B antibody titers, erythrocyte sedimentation rate (ESR), plasma C-reactive protein (CRP), and antibiotic use were recorded. Forty children (thirty-four boys and six girls; mean age: 7.65 ± 2.5 years) with motor tics were identified; thirty-three (82.5%) showed ocular tics. Children with ocular tics had significantly higher titers of anti-DNase B antibodies (p = 0.04) and CRP (p = 0.016) than those with extraocular tics. A diagnosis of PANDAS was made in 24 (60%) children. PANDAS children with oculomotor tics had significantly higher titers of anti-DNase B antibodies (p = 0.05) than those with extraocular tics. Oral antibiotics were given to 25/33 (76%) children with ocular tics and 21/24 (87.5%) with PANDAS. All treated patients showed marked improvement/complete resolution of symptoms. Results suggest that higher titers of anti-DNase B antibodies may be implicated in the pathogenesis of ocular tics in PANDAS. Oral antibiotics may be beneficial in improving ocular tics. Further research is necessary to confirm our findings.
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Affiliation(s)
- Stefano Dore
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
- Ophthalmology Unit, Azienda Ospedaliero Universitaria di Sassari, 07100 Sassari, Italy
| | - Daniele Satta
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Giacomo Boscia
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy;
| | - Arturo Carta
- Ophthalmology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Mario Fruschelli
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy;
| | - Rita Serra
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
| | - Antonio Pinna
- Department of Medicine, Surgery, and Pharmacy, University of Sassari, 07100 Sassari, Italy; (S.D.); (D.S.); (R.S.)
- Ophthalmology Unit, Azienda Ospedaliero Universitaria di Sassari, 07100 Sassari, Italy
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3
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Coelho DRA, Salvi JD, Vieira WF, Cassano P. Inflammation in obsessive-compulsive disorder: A literature review and hypothesis-based potential of transcranial photobiomodulation. J Neurosci Res 2024; 102:e25317. [PMID: 38459770 DOI: 10.1002/jnr.25317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/10/2024]
Abstract
Obsessive-compulsive disorder (OCD) is a disabling neuropsychiatric disorder that affects about 2%-3% of the global population. Despite the availability of several treatments, many patients with OCD do not respond adequately, highlighting the need for new therapeutic approaches. Recent studies have associated various inflammatory processes with the pathogenesis of OCD, including alterations in peripheral immune cells, alterations in cytokine levels, and neuroinflammation. These findings suggest that inflammation could be a promising target for intervention. Transcranial photobiomodulation (t-PBM) with near-infrared light is a noninvasive neuromodulation technique that has shown potential for several neuropsychiatric disorders. However, its efficacy in OCD remains to be fully explored. This study aimed to review the literature on inflammation in OCD, detailing associations with T-cell populations, monocytes, NLRP3 inflammasome components, microglial activation, and elevated proinflammatory cytokines such as TNF-α, CRP, IL-1β, and IL-6. We also examined the hypothesis-based potential of t-PBM in targeting these inflammatory pathways of OCD, focusing on mechanisms such as modulation of oxidative stress, regulation of immune cell function, reduction of proinflammatory cytokine levels, deactivation of neurotoxic microglia, and upregulation of BDNF gene expression. Our review suggests that t-PBM could be a promising, noninvasive intervention for OCD, with the potential to modulate underlying inflammatory processes. Future research should focus on randomized clinical trials to assess t-PBM's efficacy and optimal treatment parameters in OCD. Biomarker analyses and neuroimaging studies will be important in understanding the relationship between inflammatory modulation and OCD symptom improvement following t-PBM sessions.
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Affiliation(s)
- David Richer Araujo Coelho
- Division of Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joshua D Salvi
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Center for OCD and Related Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
- McLean Hospital, Belmont, Massachusetts, USA
| | - Willians Fernando Vieira
- Division of Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Paolo Cassano
- Division of Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Trau SP, Singer HS. Tourette Syndrome and Tic Disorders. Pediatr Rev 2024; 45:85-95. [PMID: 38296781 DOI: 10.1542/pir.2023-006014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Steven P Trau
- Division of Child Neurology, Department of Neurology, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, NC
| | - Harvey S Singer
- Department of Neurology, Johns Hopkins Hospital and the Kennedy Krieger Institute, Baltimore, MD
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5
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Vreeland A, Calaprice D, Or-Geva N, Frye RE, Agalliu D, Lachman HM, Pittenger C, Pallanti S, Williams K, Ma M, Thienemann M, Gagliano A, Mellins E, Frankovich J. Postinfectious Inflammation, Autoimmunity, and Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection, and Pediatric Acute-Onset Neuropsychiatric Disorder. Dev Neurosci 2023; 45:361-374. [PMID: 37742615 DOI: 10.1159/000534261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023] Open
Abstract
Postinfectious neuroinflammation has been implicated in multiple models of acute-onset obsessive-compulsive disorder including Sydenham chorea (SC), pediatric acute-onset neuropsychiatric syndrome (PANS), and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). These conditions are associated with a range of autoantibodies which are thought to be triggered by infections, most notably group A streptococci (GAS). Based on animal models using huma sera, these autoantibodies are thought to cross-react with neural antigens in the basal ganglia and modulate neuronal activity and behavior. As is true for many childhood neuroinflammatory diseases and rheumatological diseases, SC, PANS, and PANDAS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. In this review article, we outline the accumulating evidence supporting the role neuroinflammation plays in these disorders. We describe work with animal models including patient-derived anti-neuronal autoantibodies, and we outline imaging studies that show alterations in the basal ganglia. In addition, we present research on metabolites, which are helpful in deciphering functional phenotypes, and on the implication of sleep in these disorders. Finally, we encourage future researchers to collaborate across medical specialties (e.g., pediatrics, psychiatry, rheumatology, immunology, and infectious disease) in order to further research on clinical syndromes presenting with neuropsychiatric manifestations.
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Affiliation(s)
- Allison Vreeland
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Noga Or-Geva
- Interdepartmental Program in Immunology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Richard E Frye
- Autism Discovery and Treatment Foundation, Phoenix, Arizona, USA
| | - Dritan Agalliu
- Department of Neurology, Pathology and Cell Biology, Columbia University Irving School of Medicine, New York, New York, USA
| | - Herbert M Lachman
- Departments of Psychiatry, Medicine, Genetics, and Neuroscience, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Christopher Pittenger
- Departments of Psychiatry and Psychology, Child Study Center and Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Kyle Williams
- Department of Psychiatry Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meiqian Ma
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Margo Thienemann
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Antonella Gagliano
- Division of Child Neurology and Psychiatry, Pediatric Department of Policlinico G. Matino, University of Messina, Messina, Italy
| | - Elizabeth Mellins
- Department of Pediatrics, Program in Immunology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Frankovich
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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6
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Gagliano A, Carta A, Tanca MG, Sotgiu S. Pediatric Acute-Onset Neuropsychiatric Syndrome: Current Perspectives. Neuropsychiatr Dis Treat 2023; 19:1221-1250. [PMID: 37251418 PMCID: PMC10225150 DOI: 10.2147/ndt.s362202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) features a heterogeneous constellation of acute obsessive-compulsive disorder (OCD), eating restriction, cognitive, behavioral and/or affective symptoms, often followed by a chronic course with cognitive deterioration. An immune-mediated etiology is advocated in which the CNS is hit by different pathogen-driven (auto)immune responses. This narrative review focused on recent clinical (ie, diagnostic criteria, pre-existing neurodevelopmental disorders, neuroimaging) and pathophysiological (ie, CSF, serum, genetic and autoimmune findings) aspects of PANS. We also summarized recent points to facilitate practitioners with the disease management. Relevant literature was obtained from PubMed database which included only English-written, full-text clinical studies, case reports, and reviews. Among a total of 1005 articles, 205 were pertinent to study inclusion. Expert opinions are converging on PANS as the effect of post-infectious events or stressors leading to "brain inflammation", as it is well-established for anti-neuronal psychosis. Interestingly, differentiating PANS from either autoimmune encephalitides and Sydenham's chorea or from alleged "pure" psychiatric disorders (OCD, tics, Tourette's syndrome), reveals several overlaps and more analogies than differences. Our review highlights the need for a comprehensive algorithm to help both patients during their acute distressing phase and physicians during their treatment decision. A full agreement on the hierarchy of each therapeutical intervention is missing owing to the limited number of randomized controlled trials. The current approach to PANS treatment emphasizes immunomodulation/anti-inflammatory treatments in association with both psychotropic and cognitive-behavioral therapies, while antibiotics are suggested when an active bacterial infection is established. A dimensional view, taking into account the multifactorial origin of psychiatric disorders, should suggest neuro-inflammation as a possible shared substrate of different psychiatric phenotypes. Hence, PANS and PANS-related disorders should be considered as a conceptual framework describing the etiological and phenotypical complexity of many psychiatric disorders.
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Affiliation(s)
- Antonella Gagliano
- Department of Health Science, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Alessandra Carta
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
| | - Marcello G Tanca
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Stefano Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
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Vreeland A, Thienemann M, Cunningham M, Muscal E, Pittenger C, Frankovich J. Neuroinflammation in Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, and Pediatric Acute Onset Neuropsychiatric Syndrome. Psychiatr Clin North Am 2023; 46:69-88. [PMID: 36740356 DOI: 10.1016/j.psc.2022.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sydenham chorea (SC), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are postinfectious neuroinflammatory diseases that involve the basal ganglia and have obsessive-compulsive disorder as a major manifestation. As is true for many childhood rheumatological diseases and neuroinflammatory diseases, SC, PANDAS and PANS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. Research on the treatment of these disorders depend on three complementary modes of intervention including: treating the symptoms, treating the source of inflammation, and treating disturbances of the immune system. Future studies should aim to integrate neuroimaging, inflammation, immunogenetic, and clinical data (noting the stage in the clinical course) to increase our understanding and treatment of SC, PANDAS, PANS, and all other postinfectious/immune-mediated behavioral disorders.
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Affiliation(s)
- Allison Vreeland
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA; Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA.
| | - Margo Thienemann
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA; Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA
| | - Madeleine Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Eyal Muscal
- Department of Rheumatology, Texas Children's Hospital, Houston, TX, USA
| | | | - Jennifer Frankovich
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA; Division of Pediatrics, Department of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
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Kirvan CA, Canini H, Swedo SE, Hill H, Veasy G, Jankelow D, Kosanke S, Ward K, Zhao YD, Alvarez K, Hedrick A, Cunningham MW. IgG2 rules: N-acetyl-β-D-glucosamine-specific IgG2 and Th17/Th1 cooperation may promote the pathogenesis of acute rheumatic heart disease and be a biomarker of the autoimmune sequelae of Streptococcus pyogenes. Front Cardiovasc Med 2023; 9:919700. [PMID: 36815140 PMCID: PMC9939767 DOI: 10.3389/fcvm.2022.919700] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
Antecedent group A streptococcal pharyngitis is a well-established cause of acute rheumatic fever (ARF) where rheumatic valvular heart disease (RHD) and Sydenham chorea (SC) are major manifestations. In ARF, crossreactive antibodies and T cells respond to streptococcal antigens, group A carbohydrate, N-acetyl-β-D-glucosamine (GlcNAc), and M protein, respectively, and through molecular mimicry target heart and brain tissues. In this translational human study, we further address our hypothesis regarding specific pathogenic humoral and cellular immune mechanisms leading to streptococcal sequelae in a small pilot study. The aims of the study were to (1) better understand specific mechanisms of pathogenesis in ARF, (2) identify a potential early biomarker of ARF, (3) determine immunoglobulin G (IgG) subclasses directed against GlcNAc, the immunodominant epitope of the group A carbohydrate, by reaction of ARF serum IgG with GlcNAc, M protein, and human neuronal cells (SK-N-SH), and (4) determine IgG subclasses deposited on heart tissues from RHD. In 10 pediatric patients with RHD and 6 pediatric patients with SC, the serum IgG2 subclass reacted significantly with GlcNAc, and distinguished ARF from 7 pediatric patients with uncomplicated pharyngitis. Three pediatric patients who demonstrated only polymigrating arthritis, a major manifestation of ARF and part of the Jones criteria for diagnosis, lacked the elevated IgG2 subclass GlcNAc-specific reactivity. In SC, the GlcNAc-specific IgG2 subclass in cerebrospinal fluid (CSF) selectively targeted human neuronal cells as well as GlcNAc in the ELISA. In rheumatic carditis, the IgG2 subclass preferentially and strongly deposited in valve tissues (n = 4) despite elevated concentrations of IgG1 and IgG3 in RHD sera as detected by ELISA to group A streptococcal M protein. Although our human study of ARF includes a very small limited sample set, our novel research findings suggest a strong IgG2 autoantibody response against GlcNAc in RHD and SC, which targeted heart valves and neuronal cells. Cardiac IgG2 deposition was identified with an associated IL-17A/IFN-γ cooperative signature in RHD tissue which displayed both IgG2 deposition and cellular infiltrates demonstrating these cytokines simultaneously. GlcNAc-specific IgG2 may be an important autoantibody in initial stages of the pathogenesis of group A streptococcal sequelae, and future studies will determine if it can serve as a biomarker for risk of RHD and SC or early diagnosis of ARF.
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Affiliation(s)
- Christine A. Kirvan
- Department of Biological Sciences, California State University, Sacramento, CA, United States
| | - Heather Canini
- Department of Biological Sciences, California State University, Sacramento, CA, United States
| | - Susan E. Swedo
- Pediatrics and Developmental Neuropsychiatry Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, United States
| | - Harry Hill
- Departments of Pediatrics, Infectious Diseases, Cardiology, and Pathology, University of Utah College of Medicine, Salt Lake City, UT, United States
| | - George Veasy
- Departments of Pediatrics, Infectious Diseases, Cardiology, and Pathology, University of Utah College of Medicine, Salt Lake City, UT, United States
| | - David Jankelow
- Division of Cardiology, University of Witwatersrand, Johannesburg, South Africa
| | - Stanley Kosanke
- Department of Comparative Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Kent Ward
- Department of Pediatrics, Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Yan D. Zhao
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Kathy Alvarez
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Andria Hedrick
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Madeleine W. Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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9
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Rafeek RAM, Hamlin AS, Andronicos NM, Lawlor CS, McMillan DJ, Sriprakash KS, Ketheesan N. Characterization of an experimental model to determine streptococcal M protein–induced autoimmune cardiac and neurobehavioral abnormalities. Immunol Cell Biol 2022; 100:653-666. [PMID: 35792671 PMCID: PMC9545610 DOI: 10.1111/imcb.12571] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 11/29/2022]
Abstract
Group A streptococcal (GAS) infection is associated with a spectrum of autoimmune diseases including acute rheumatic fever/rheumatic heart disease (ARF/RHD) and neurobehavioral abnormalities. Antibodies against GAS M proteins cross‐react with host tissue proteins in the heart and brain leading to the symptomatology observed in ARF/RHD. As throat carriage of Streptococcus dysgalactiae subspecies equisimilis (SDSE) has been reported to be relatively high in some ARF/RHD endemic regions compared with GAS, and both SDSE and GAS express coiled‐coil surface protein called M protein, we hypothesized that streptococci other than GAS can also associated with ARF/RHD and neurobehavioral abnormalities. Neurobehavioral assessments and electrocardiography were performed on Lewis rats before and after exposure to recombinant GAS and SDSE M proteins. Histological assessments were performed to confirm inflammatory changes in cardiac and neuronal tissues. ELISA and Western blot analysis were performed to determine the cross‐reactivity of antibodies with host connective, cardiac and neuronal tissue proteins. Lewis rats injected with M proteins either from GAS or SDSE developed significant cardiac functional and neurobehavioral abnormalities in comparison to control rats injected with phosphate‐buffered saline. Antibodies against GAS and SDSE M proteins cross‐reacted with cardiac, connective and neuronal proteins. Serum from rats injected with streptococcal antigens showed higher immunoglobulin G binding to the striatum and cortex of the brain. Cardiac and neurobehavioral abnormalities observed in our experimental model were comparable to the cardinal symptoms observed in patients with ARF/RHD. Here for the first time, we demonstrate in an experimental model that M proteins from different streptococcal species could initiate and drive the autoimmune‐mediated cardiac tissue damage and neurobehavioral abnormalities.
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Affiliation(s)
- Rukshan AM Rafeek
- School of Science & Technology University of New England Armidale NSW Australia
| | - Adam S Hamlin
- School of Science & Technology University of New England Armidale NSW Australia
| | | | - Craig S Lawlor
- School of Science & Technology University of New England Armidale NSW Australia
| | - David J McMillan
- School of Science & Technology University of New England Armidale NSW Australia
- School of Science, Technology, Engineering and Genecology Research Centre University of the Sunshine Coast Sippy Downs QLDAustralia
| | - Kadaba S Sriprakash
- School of Science & Technology University of New England Armidale NSW Australia
- Infection and Inflammation Laboratory QIMR Berghofer Medical Research Institute Herston QLDAustralia
| | - Natkunam Ketheesan
- School of Science & Technology University of New England Armidale NSW Australia
- School of Science, Technology, Engineering and Genecology Research Centre University of the Sunshine Coast Sippy Downs QLDAustralia
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Blum K, Dennen CA, Braverman ER, Gupta A, Baron D, Downs BW, Bagchi D, Thanos P, Pollock M, Khalsa J, Elman I, Bowirrat A, Badgaiyan RA. Hypothesizing That Pediatric Autoimmune Neuropsychiatric Associated Streptococcal (PANDAS) Causes Rapid Onset of Reward Deficiency Syndrome (RDS) Behaviors and May Require Induction of "Dopamine Homeostasis". OPEN JOURNAL OF IMMUNOLOGY 2022; 12:65-75. [PMID: 36407790 PMCID: PMC9670240 DOI: 10.4236/oji.2022.123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with group A streptococcal infections (PANDAS) is a concept that is used to characterize a subset of children with neuropsychiatric symptoms, tic disorders, or obsessive-compulsive disorder (OCD), whose symptoms are exacerbated by group A streptococcal (GAS) infection. PANDAS has been known to cause a sudden onset of reward deficiency syndrome (RDS). RDS includes multiple disorders that are characterized by dopaminergic signaling dysfunction in the brain reward cascade (BRC), which may result in addiction, depression, avoidant behaviors, anxiety, tic disorders, and/or OCD. According to research by Blum et al., the dopamine receptor D2 (DRD2) gene polymorphisms are important prevalent genetic determinants of RDS. The literature demonstrates that infections like Borrelia and Lyme, as well as other infections like group A beta-hemolytic streptococcal (GABHS), can cause an autoimmune reaction and associated antibodies target dopaminergic loci in the mesolimbic region of the brain, which interferes with brain function and potentially causes RDS-like symptoms/behaviors. The treatment of PANDAS remains controversial, especially since there have been limited efficacy studies to date. We propose an innovative potential treatment for PANDAS based on previous clinical trials using a pro-dopamine regulator known as KB220 variants. Our ongoing research suggests that achieving "dopamine homeostasis" by precision-guided DNA testing and pro-dopamine modulation could result in improved therapeutic outcomes.
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Affiliation(s)
- Kenneth Blum
- Center for Mental Health and Sports, Psychiatry, Western University Health Sciences, Pomona, USA
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, USA
- Department Psychiatry, Boonshoff School of Medicine, Wright University, Dayton, USA
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
- Department of Psychiatry, School of Medicine, University of Vermont, Burlington, USA
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health Northeast, Philadelphia, USA
| | | | | | - David Baron
- Center for Mental Health and Sports, Psychiatry, Western University Health Sciences, Pomona, USA
| | - Bernard William Downs
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
| | - Debasis Bagchi
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
- Department of Pharmaceutical Sciences, Texas Southern University, Houston, USA
| | - Panayotis Thanos
- Department of Psychology & Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions (BNNLA), Research Institute on Addictions, University at Buffalo, Buffalo, USA
| | - Maureen Pollock
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, USA
| | - Jag Khalsa
- Department of Microbiology, Immunology, and Tropical Medicine, School of Medicine, George Washington University, Washington DC, USA
| | - Igor Elman
- Cambridge Health Alliance, Harvard Medical School, Cambridge, USA
| | - Abdalla Bowirrat
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Rajendra A. Badgaiyan
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, USA
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Health Science Center, San Antonio, USA
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11
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Hoffman KL, Cano-Ramírez H. Pediatric neuropsychiatric syndromes associated with infection and microbiome alterations: clinical findings, possible role of the mucosal epithelium, and strategies for the development of new animal models. Expert Opin Drug Discov 2022; 17:717-731. [PMID: 35543072 DOI: 10.1080/17460441.2022.2074396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Subsets of pediatric obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) respectively have been associated with respiratory tract infections and alterations in the intestinal microbiome. Pediatric Acute-onset Neuropsychiatric Syndromes (PANS) refers to the sudden onset of neuropsychiatric symptoms that are triggered by several different infectious and non-infectious factors. Clinical studies and animal modeling are consistent with the proposal that inflammation plays an important etiological role in PANS, as well as in ASD associated with gut dysbiosis. AREAS COVERED The authors provide an overview of clinical studies of PANS and ASD associated with gastrointestinal symptoms, as well as the current strategies for studying these syndromes in rodent models. Finally, the authors highlight similarities between these syndromes that may provide clues to common etiological mechanisms. EXPERT OPINION Although data from existing animal models are consistent with an important role for anti-neuronal antibodies in PANS triggered by GAS infection, we lack models for identifying pathophysiological mechanisms of PANS associated with other infectious and non-infectious triggers. The authors propose a strategy for developing such models that incorporates known vulnerability and triggering factors for PANS into the modeling process. This novel strategy should expand our understanding of the pathophysiology of PANS, as well as facilitate the development of new pharmacological treatments for PANS and related syndromes.
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Affiliation(s)
- Kurt Leroy Hoffman
- Centro de Investigación en Reproducción Animal Dr. Carlos Beyer Flores (CIRA), Universidad Autónoma de Tlaxcala - Centro de Investigación de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN)
| | - Hugo Cano-Ramírez
- Centro de Investigación en Reproducción Animal Dr. Carlos Beyer Flores (CIRA), Universidad Autónoma de Tlaxcala - Centro de Investigación de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN)
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12
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Acute Rheumatic Fever and Rheumatic Heart Disease: Highlighting the Role of Group A Streptococcus in the Global Burden of Cardiovascular Disease. Pathogens 2022; 11:pathogens11050496. [PMID: 35631018 PMCID: PMC9145486 DOI: 10.3390/pathogens11050496] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/27/2022] [Accepted: 04/01/2022] [Indexed: 02/01/2023] Open
Abstract
Group A Streptococcus (GAS) causes superficial and invasive infections and immune mediated post-infectious sequalae (including acute rheumatic fever/rheumatic heart disease). Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are important determinants of global cardiovascular morbidity and mortality. ARF is a multiorgan inflammatory disease that is triggered by GAS infection that activates the innate immune system. In susceptible hosts the response against GAS elicits autoimmune reactions targeting the heart, joints, brain, skin, and subcutaneous tissue. Repeated episodes of ARF—undetected, subclinical, or diagnosed—may progressively lead to RHD, unless prevented by periodic administration of penicillin. The recently modified Duckett Jones criteria with stratification by population risk remains relevant for the diagnosis of ARF and includes subclinical carditis detected by echocardiography as a major criterion. Chronic RHD is defined by valve regurgitation and/or stenosis that presents with complications such as arrhythmias, systemic embolism, infective endocarditis, pulmonary hypertension, heart failure, and death. RHD predominantly affects children, adolescents, and young adults in LMICs. National programs with compulsory notification of ARF/RHD are needed to highlight the role of GAS in the global burden of cardiovascular disease and to allow prioritisation of these diseases aimed at reducing health inequalities and to achieve universal health coverage.
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13
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Teixeira AL, Vasconcelos LP, Nunes MDCP, Singer H. Sydenham's chorea: from pathophysiology to therapeutics. Expert Rev Neurother 2021; 21:913-922. [PMID: 34353207 DOI: 10.1080/14737175.2021.1965883] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sydenham's chorea is an autoimmune chorea emerging after a group A beta-hemolytic streptococcal (GABHS) infection, i.e. a rheumatic chorea with or without the presence of carditis or arthritis. The disorder, defined by the presence of chorea, is also associated with cognitive and behavioral symptoms, including emotional lability, anxiety, depressive and obsessive-compulsive symptoms. The authors review the pathophysiology, clinical characteristics, and available evidence on therapeutic strategies, the latter including the secondary prevention of GABHS infections, reduction of chorea, and immune modulation. Sydenham's chorea has been regarded as a model for pediatric autoimmune neuropsychiatric disorders, however, the field is marked by conflicting results and controversies. Regarding therapeutics, there are limited high-quality interventional studies and the selection of treatment strategy often relies on the clinician's experience. A serial treatment algorithm is presented based upon the severity of clinical presentation and response to symptomatic pharmacotherapy.
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Affiliation(s)
- Antonio L Teixeira
- Infectious Diseases and Tropical Medicine Graduation Program, School of Medicine, Universidade Federal De Minas Gerais, Belo Horizonte, Brazil.,Institute of Education and Research, Santa Casa Bh, Belo Horizonte, Brazil.,Neuropsychiatry Program, Ut Health Science Center at Houston, USA
| | - Luiz P Vasconcelos
- Infectious Diseases and Tropical Medicine Graduation Program, School of Medicine, Universidade Federal De Minas Gerais, Belo Horizonte, Brazil
| | - Maria do Carmo Pereira Nunes
- Infectious Diseases and Tropical Medicine Graduation Program, School of Medicine, Universidade Federal De Minas Gerais, Belo Horizonte, Brazil
| | - Harvey Singer
- Department of Neurology, Johns Hopkins Medicine and Kennedy Krieger Institute, Baltimore, MD, USA
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Rafeek RAM, Lobbe CM, Wilkinson EC, Hamlin AS, Andronicos NM, McMillan DJ, Sriprakash KS, Ketheesan N. Group A streptococcal antigen exposed rat model to investigate neurobehavioral and cardiac complications associated with post-streptococcal autoimmune sequelae. Animal Model Exp Med 2021; 4:151-161. [PMID: 34179722 PMCID: PMC8212825 DOI: 10.1002/ame2.12164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/03/2021] [Indexed: 12/25/2022] Open
Abstract
Background The neuropsychiatric disorders due to post-streptococcal autoimmune complications such as Sydenham's chorea (SC) are associated with acute rheumatic fever and rheumatic heart disease (ARF/RHD). An animal model that exhibits characteristics of both cardiac and neurobehavioral defects in ARF/RHD would be an important adjunct for future studies. Since age, gender, strain differences, and genotypes impact on the development of autoimmunity, we investigated the behavior of male and female Wistar and Lewis rat strains in two age cohorts (<6 weeks and >12 weeks) under normal husbandry conditions and following exposure to group A streptococcus (GAS). Methods Standard behavioral assessments were performed to determine the impairments in fine motor control (food manipulation test), gait and balance (beam walking test), and obsessive-compulsive behavior (grooming and marble burying tests). Furthermore, electrocardiography, histology, and behavioral assessments were performed on male and female Lewis rats injected with GAS antigens. Results For control Lewis rats there were no significant age and gender dependent differences in marble burying, food manipulation, beam walking and grooming behaviors. In contrast significant age-dependent differences were observed in Wistar rats in all the behavioral tests except for food manipulation. Therefore, Lewis rats were selected for further experiments to determine the effect of GAS. After exposure to GAS, Lewis rats demonstrated neurobehavioral abnormalities and cardiac pathology akin to SC and ARF/RHD, respectively. Conclusion We have characterised a new model that provides longitudinal stability of age-dependent behavior, to simultaneously investigate both neurobehavioral and cardiac abnormalities associated with post-streptococcal complications.
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Affiliation(s)
| | - Catherine M. Lobbe
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
| | - Ethan C. Wilkinson
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
| | - Adam S. Hamlin
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
| | | | - David J. McMillan
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
- School of Science, Technology, Engineering and Genecology Research CentreUniversity of the Sunshine CoastMaroochydore DCQLDAustralia
| | - Kadaba S. Sriprakash
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
- QIMR Berghofer Medical Research InstituteHerstonQLDAustralia
| | - Natkunam Ketheesan
- School of Science & TechnologyUniversity of New EnglandArmidaleNSWAustralia
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15
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Cross A, Bouboulis D, Shimasaki C, Jones CR. Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery. Front Psychiatry 2021; 12:505941. [PMID: 33603684 PMCID: PMC7884317 DOI: 10.3389/fpsyt.2021.505941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/04/2021] [Indexed: 12/03/2022] Open
Abstract
This case report describes the diagnosis and treatment of a pre-pubertal (onset at age 7) Caucasian female with serological evidence of Lyme disease accompanied by multiple neuropsychiatric symptoms 6 months following a vacation in a tick endemic area of the United States. Prior to the diagnosis of Lyme disease, the patient also met the clinical diagnostic criteria for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep), with serological evidence of three distinct episodes of streptococcal pharyngitis. All three episodes of strep occurred during the 6-months interval between suspected Lyme disease exposure and the onset of multiple neuropsychiatric symptoms. Her sometimes incapacitating symptoms followed a relapsing and remitting course that impacted her personal, family, social, and academic domains. Over a span of 31 consecutive months of treatment with various antimicrobials and three courses of intravenous immunoglobulins (IVIg) she experienced complete remission and remains symptom free at the time of this publication. Written permission was obtained from the minor patient's mother allowing the submission and publication of this case study.
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Affiliation(s)
- Amy Cross
- Moleculera Labs, Oklahoma City, OK, United States
| | - Denis Bouboulis
- Advanced Allergy, Immunology and Asthma, Darien, CT, United States
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16
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Prato A, Gulisano M, Scerbo M, Barone R, Vicario CM, Rizzo R. Diagnostic Approach to Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS): A Narrative Review of Literature Data. Front Pediatr 2021; 9:746639. [PMID: 34778136 PMCID: PMC8580040 DOI: 10.3389/fped.2021.746639] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/24/2021] [Indexed: 12/12/2022] Open
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinical conditions characterized by the sudden onset of obsessive-compulsive disorder and/or tics, often accompanied by other behavioral symptoms in a group of children with streptococcal infection. PANDAS-related disorders, including pediatric acute-onset neuropsychiatric syndrome (PANS), childhood acute neuropsychiatric symptoms (CANS), and pediatric infection triggered autoimmune neuropsychiatric disorders (PITANDs), have also been described. Since first defined in 1998, PANDAS has been considered a controversial diagnosis. A comprehensive review of the literature was performed on PubMed and Scopus databases, searching for diagnostic criteria and diagnostic procedures of PANDAS and related disorders. We propose a test panel to support clinicians in the workout of PANDAS/PANS patients establishing an appropriate treatment. However, further studies are needed to improve our knowledge on these acute-onset neuropsychiatric conditions.
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Affiliation(s)
- Adriana Prato
- Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy.,Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Mariangela Gulisano
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Miriam Scerbo
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Rita Barone
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Carmelo M Vicario
- Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy
| | - Renata Rizzo
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
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17
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Dop D, Marcu IR, Padureanu R, Niculescu CE, Padureanu V. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (Review). Exp Ther Med 2021; 21:94. [PMID: 33363605 PMCID: PMC7725005 DOI: 10.3892/etm.2020.9526] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/26/2020] [Indexed: 12/04/2022] Open
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinically characterized by the sudden onset of obsessive-compulsive manifestations, motor and verbal tics, as well as other behavioral symptoms in a group of children with B-hemolytic streptococcal infection. PANDAS are considered autoimmune diseases because the streptococcal infection and response can be demonstrated. The most frequent physiopathological mechanism is molecular mimicry: A foreign antigen shares sequence or structural similarities with self-antigens. A thorough review of the literature was carried out using the PubMed database and SCOPUS, searching for immunological, clinical and microbiological aspects, as well as the treatment of the PANDAS syndrome. The diagnosis is clinical and it requires a careful medical history and a thorough physical examination, while the treatment is complex. Untreated or unrecognized manifestations of PANDAS can increase the risk of obsessive-compulsive manifestations and tics during adulthood. Taking this into consideration, further studies are required to establish the best method of therapy.
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Affiliation(s)
- Dalia Dop
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Iulia Rahela Marcu
- Department of Physical and Rehabilitation Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Rodica Padureanu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Carmen Elena Niculescu
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
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Chain JL, Alvarez K, Mascaro-Blanco A, Reim S, Bentley R, Hommer R, Grant P, Leckman JF, Kawikova I, Williams K, Stoner JA, Swedo SE, Cunningham MW. Autoantibody Biomarkers for Basal Ganglia Encephalitis in Sydenham Chorea and Pediatric Autoimmune Neuropsychiatric Disorder Associated With Streptococcal Infections. Front Psychiatry 2020; 11:564. [PMID: 32670106 PMCID: PMC7328706 DOI: 10.3389/fpsyt.2020.00564] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
Movement, behavioral, and neuropsychiatric disorders in children have been linked to infections and a group of anti-neuronal autoantibodies, implying dopamine receptor-mediated encephalitis within the basal ganglia. The purpose of this study was to determine if anti-neuronal biomarkers, when used as a group, confirmed the acute disease in Sydenham chorea (SC) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS). IgG autoantibodies against four neuronal autoantigens (tubulin, lysoganglioside GM1, and dopamine receptors D1 and D2) were detected in SC sera (N=8), sera and/or cerebrospinal fluid (CSF) from two groups of PANDAS cases (N=25 first group and N=35 second group), sera from Tourette's syndrome (N=18), obsessive-compulsive disorder (N=25), attention deficit hyperactivity disorder (N=18), and healthy controls (N=28) by direct enzyme-linked immunosorbent assay (ELISA). IgG specific for neuronal autoantigens was significantly elevated during the acute symptomatic phase, and the activity of calcium/calmodulin-dependent protein kinase II (CaMKII) pathway was significantly elevated in human neuronal cells. Five assays confirmed the disease in SC and in two groups of children with PANDAS. In 35 acute onset PANDAS patients, 32 sera (91.4%) were positive for one or more of the anti-neuronal autoantibodies compared with 9 of 28 healthy controls (32.1%, p<0.0001). Importantly, CSF of 32 (91.4%) PANDAS patients had one or more detectable anti-neuronal autoantibody titers and CaMKII activation. Among healthy control subjects with elevated serum autoantibody titers for individual antigens, none (0%) were positively associated with elevated positive CaMKII activation, which was a striking contrast to the sera of PANDAS subjects, who had 76-89% positive association with elevated individual autoantibody titers and positive CaMKII activity. At 6 months follow-up, symptoms improved for more than 80% of PANDAS subjects, and serum autoantibody titers also significantly decreased. Results reported herein and previously published studies in our laboratory suggest the antibody biomarkers may be a useful adjunct to clinical diagnosis of SC, PANDAS, and related disorders and are the first known group of autoantibodies detecting dopamine receptor-mediated encephalitis in children.
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Affiliation(s)
- Jennifer L. Chain
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Kathy Alvarez
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Adita Mascaro-Blanco
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sean Reim
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Rebecca Bentley
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Rebecca Hommer
- Section on Behavioral Pediatrics, National Institute of Mental Health (NIMH), Bethesda, MD, United States
| | - Paul Grant
- Section on Behavioral Pediatrics, National Institute of Mental Health (NIMH), Bethesda, MD, United States
| | - James F. Leckman
- Child Study Center, Yale School of Medicine, New Haven, CT, United States
| | - Ivana Kawikova
- Section of Pediatric Neurology, Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Kyle Williams
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Julie A. Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Susan E. Swedo
- Section on Behavioral Pediatrics, National Institute of Mental Health (NIMH), Bethesda, MD, United States
| | - Madeleine W. Cunningham
- Departments of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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19
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Cabrera-Mendoza B, Genis-Mendoza AD, Nicolini H. Diagnosis in PANDAS: An Update. CURRENT PSYCHIATRY RESEARCH AND REVIEWS 2020. [DOI: 10.2174/2666082215666190917161514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:The last twenty years have seen major advancements in unraveling the etiology and the identification of biological markers of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci (PANDAS). However, this body of evidence has not yet been translated into a clinical setting.Objective:We will review the most important studies to date on PANDAS, emphasizing those whose advances could improve the diagnosis of these disorders. We also suggest the need for updated diagnosis criteria integrating the recent findings from the hereby included studies.Methods:Consulting the PubMed database, a literature review of the last twenty-one years (between 1998 and 2019) was carried out using the terms “PANDAS” and “pediatric autoimmune neuropsychiatric disorders” in combination with “diagnosis” and “markers”. The search resulted in 175 hits from which we selected clinical cases, original investigations, and clinical reviews.Results:This review offers a compilation of the most important studies performed to date regarding the clinical presentation and potential biological markers of PANDAS. Moreover, we suggest the refinement of some aspects in the current diagnosis criteria, such as focusing on specific symptoms and the inclusion of neuroimaging and peripheral markers.Conclusion:The identification of specific biological markers in PANDAS is crucial for its diagnosis and opportune treatment. Future research will determine whether PANDAS require separated diagnostic and therapeutic measures or if it should be included in recently proposed categories such as Pediatric Acute Neuropsychiatric Syndrome (PANS) or Childhood Acute Neuropsychiatric Syndrome (CANS).
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Affiliation(s)
- Brenda Cabrera-Mendoza
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, National Institute of Genomic Medicine (INMEGEN), CDMX, Mexico
| | - Alma Delia Genis-Mendoza
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, National Institute of Genomic Medicine (INMEGEN), CDMX, Mexico
| | - Humberto Nicolini
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, National Institute of Genomic Medicine (INMEGEN), CDMX, Mexico
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20
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Shimasaki C, Frye RE, Trifiletti R, Cooperstock M, Kaplan G, Melamed I, Greenberg R, Katz A, Fier E, Kem D, Traver D, Dempsey T, Latimer ME, Cross A, Dunn JP, Bentley R, Alvarez K, Reim S, Appleman J. Evaluation of the Cunningham Panel™ in pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS): Changes in antineuronal antibody titers parallel changes in patient symptoms. J Neuroimmunol 2019; 339:577138. [PMID: 31884258 DOI: 10.1016/j.jneuroim.2019.577138] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 12/12/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This retrospective study examined whether changes in patient pre- and post-treatment symptoms correlated with changes in anti-neuronal autoantibody titers and the neuronal cell stimulation assay in the Cunningham Panel in patients with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS), and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). METHODS In an analysis of all tests consecutively performed in Moleculera Labs' clinical laboratory from April 22, 2013 to December 31, 2016, we identified 206 patients who were prescribed at least one panel prior to and following treatment, and who met the PANDAS/PANS diagnostic criteria. Patient follow-up was performed to collect symptoms and treatment or medical intervention. Of the 206 patients, 58 met the inclusion criteria of providing informed consent/assent and documented pre- and post-treatment symptoms. Clinician and parent-reported symptoms after treatment or medical intervention were categorized as "Improved/Resolved" (n = 34) or "Not-Improved/Worsened" (n = 24). These were analyzed for any association between changes in clinical status and changes in Cunningham panel test results. Clinical assay performance was also evaluated for reproducibility and reliability. RESULTS Comparison of pre- and post-treatment status revealed that the Cunningham Panel results correlated with changes in patient's neuropsychiatric symptoms. Based upon the change in the number of positive tests, the overall accuracy was 86%, the sensitivity and specificity were 88% and 83% respectively, and the Area Under the Curve (AUC) was 93.4%. When evaluated by changes in autoantibody levels, we observed an overall accuracy of 90%, a sensitivity of 88%, a specificity of 92% and an AUC of 95.7%. Assay reproducibility for the calcium/calmodulin-dependent protein kinase II (CaMKII) revealed a correlation coefficient of 0.90 (p < 1.67 × 10-6) and the ELISA assays demonstrated test-retest reproducibility comparable with other ELISA assays. CONCLUSION This study revealed a strong positive association between changes in neuropsychiatric symptoms and changes in the level of anti-neuronal antibodies and antibody-mediated CaMKII human neuronal cell activation. These results suggest there may be clinical utility in monitoring autoantibody levels and stimulatory activity against these five neuronal antigen targets as an aid in the diagnosis and treatment of infection-triggered autoimmune neuropsychiatric disorders. Future prospective studies should examine the feasibility of predicting antimicrobial and immunotherapy responses with the Cunningham Panel.
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Affiliation(s)
- Craig Shimasaki
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America.
| | - Richard E Frye
- Barrow Neurological Institute, Phoenix Children's Hospital, 1919 East Thomas Rd, Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Rosario Trifiletti
- The PANS/PANDAS Institute, 545 Island Road, Suite 1D, Ramsey, NJ 07446, United States of America
| | - Michael Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, MO, United States of America
| | - Gary Kaplan
- The Kaplan Center for Integrative Medicine, 6828 Elm Street, Suite 300, McLean, VA 22101, United States of America
| | - Isaac Melamed
- IMMUNOe Health and Research Centers, 6801 South Yosemite Street, Centennial, CO 80112, United States of America
| | - Rosalie Greenberg
- Medical Arts Psychotherapy Associates, P.A., 33 Overlook Road, Suite 406, Summit, NJ 07901, United States of America
| | - Amiram Katz
- Private Practice Neurology, 325 Boston Post Rd., Suite 1D, Orange, CT 06477, United States of America
| | - Eric Fier
- TherapyWorks ATL, 621 North Avenue NE, Atlanta, GA 30308, United States of America
| | - David Kem
- Section of Endocrinology and Diabetes, University of Oklahoma Department of Medicine, 1000 N Lincoln Blvd., Oklahoma City, OK 73104, United States of America
| | - David Traver
- 1261 E. Hillsdale Blvd., Foster City, CA 94404, United States of America
| | - Tania Dempsey
- Armonk Integrative Medicine, Private Practice, Pediatrics, 99 Business Park Drive, Armonk, NY 10504, United States of America
| | - M Elizabeth Latimer
- Latimer Neurology Center, 1101 30th Street NW Suite #320, Washington, DC 20007, United States of America
| | - Amy Cross
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Joshua P Dunn
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Rebecca Bentley
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Kathy Alvarez
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America; The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States of America
| | - Sean Reim
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States of America
| | - James Appleman
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
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21
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Lepri G, Rigante D, Bellando Randone S, Meini A, Ferrari A, Tarantino G, Cunningham MW, Falcini F. Clinical-Serological Characterization and Treatment Outcome of a Large Cohort of Italian Children with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2019; 29:608-614. [PMID: 31140830 DOI: 10.1089/cap.2018.0151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: Pediatric autoimmune neuropsychiatric disorder associated with Streptococcus pyogenes infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are emerging immune-mediated encephalopathies characterized by sudden onset of seemingly inexplicable complex neuropsychiatric symptoms, including obsessions, compulsions, and heterogeneous tics, which occur in children. Main goal of this study was to report our experience in a large cohort of Italian children affected by either PANDAS or PANS and treated long term with an antibiotic regimen similar to that used for acute rheumatic fever. Patients and Methods: The clinical charts of a cohort of 371 consecutive Italian children, 345 with PANDAS (93.0%) and 26 with PANS (7.0%), were retrospectively evaluated. Antistreptococcal, antinuclear antibodies, and serologic evaluation for a group of common autoantibodies and microbial agents were also assessed. A strict differential diagnosis with other autoimmune diseases displaying neuropsychiatric manifestations was performed. Results: Antistreptolysin O and anti-DNase B antibody titers were tested and were positive in all PANDAS subjects, but negative in PANS. Anti-Mycoplasma pneumoniae antibodies and anti-Epstein-Barr virus Nuclear Antigen antibodies were found positive in 11 (42.3%) and 5 (19.2%) patients with PANS, respectively. Among PANDAS cases, a clear streptococcal infection was clinically evident at the onset of neurological symptoms in only 74 patients (21.4%), whereas the relationship with Streptococcus pyogenes was confirmed by serologic tests in the other 271 (78.6%). All patients fulfilling the diagnostic criteria for PANDAS (n = 345) received amoxicillin/clavulanic acid for 10-21 days at diagnosis, while those who were diagnosed with PANS (n = 26) received treatment according to the causative agent. Thereafter, all PANDAS/PANS patients received prophylaxis with benzathine benzylpenicillin for an overall period of at least 5 years to prevent subsequent potential streptococcal infections. To date, 75.0% of PANDAS patients (n = 258) have shown an improvement of neurologic symptoms, mainly observed within 3-5 months of treatment for PANDAS cases, while 88.4% of PANS patients (n = 23) have improved after 6-12 months. Infection-related relapses of neurologic manifestations were observed in both PANDAS and PANS patients (n = 167 out of 371; 45% of the total cohort) in the long term. Conclusions: Our study has confirmed the usefulness of the preliminary diagnostic criteria for PANDAS and PANS, revealing also the importance of early diagnosis to reduce the risk of evolution toward disabling chronic neurologic sequelae. Long-term antibiotic prophylaxis has resulted in a substantial benefit to reduce neurological symptoms for the majority of PANDAS and PANS patients over a 7-year period.
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Affiliation(s)
- Gemma Lepri
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Bellando Randone
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
| | - Antonella Meini
- Department of Pediatrics, Unit of Immunology and Pediatric Rheumatology, University of Brescia, Spedali Civili, Brescia, Italy
| | - Alessandra Ferrari
- Department of Pediatrics, Unit of Immunology and Pediatric Rheumatology, University of Brescia, Spedali Civili, Brescia, Italy
| | - Giusyda Tarantino
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy
| | - Madeleine W Cunningham
- Department of Microbiology and Immunology, Biomedical Research Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Fernanda Falcini
- Department of Experimental and Clinical Medicine and Department of Biomedicine, Division of Rheumatology AOUC & Transition Clinic, University of Florence, Florence, Italy
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22
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Baglioni V, Coutinho E, Menassa DA, Giannoccaro MP, Jacobson L, Buttiglione M, Petruzzelli O, Cardona F, Vincent A. Antibodies to neuronal surface proteins in Tourette Syndrome: Lack of evidence in a European paediatric cohort. Brain Behav Immun 2019; 81:665-669. [PMID: 31425826 DOI: 10.1016/j.bbi.2019.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022] Open
Abstract
In Tourette Syndrome (TS) a role for autoantibodies directed against neuronal proteins has long been suspected, but so far results are still inconsistent. The aim of this study was to look for antibodies to specific or undefined neuronal proteins that could be involved in the aetiology of the disease. Sera from children with Tourette Syndrome or another chronic tic disorder (TS/TD), collected as part of the longitudinal European Multicenter Tics in Children Study, were investigated. Participants included 30 siblings of patients with TS/TD prior to developing tics (preclinical stage) and the same children after the first tic onset (onset), and 158 patients in the chronic phase undergoing an acute relapse (exacerbation). Presence of antibodies binding to rodent brain tissue was assessed by immunohistology on rat brain sections and by immunofluorescent staining of live hippocampal neurons. Live cell-based assays were used to screen for antibodies to NMDAR, CASPR2, LGI1, AMPAR and GABAAR. Immunohistology indicated evidence of antibodies reactive with brain tissue, binding mainly to the hippocampus, the basal ganglia or the cerebellum in 26/218 (12%), with 8% of the preclinical or onset sera binding to the dentate gyrus/CA3 region or cerebellum. Only two individuals (one pre-clinical, one chronic) had antibodies binding the NMDAR and the binding was only weakly positive. No other specific antibodies were detected. Despite some immunoreactivity towards neuronal antigens on brain tissue, this was not mirrored by antibodies binding to live neurons, suggesting the presence of non-specific antibodies or those that bind non-pathogenic intracellular epitopes. NMDAR or the other neuronal surface antibodies tested were very infrequent in these patients. The evidence for pathogenic antibodies that could be causative of TS is weak.
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Affiliation(s)
- V Baglioni
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK; Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - E Coutinho
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - D A Menassa
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - M P Giannoccaro
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - L Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - M Buttiglione
- Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - O Petruzzelli
- Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - F Cardona
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - A Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
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23
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Gerentes M, Pelissolo A, Rajagopal K, Tamouza R, Hamdani N. Obsessive-Compulsive Disorder: Autoimmunity and Neuroinflammation. Curr Psychiatry Rep 2019; 21:78. [PMID: 31367805 DOI: 10.1007/s11920-019-1062-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Here, we propose to review the immuno-inflammatory hypothesis in OCD given the concurrent incidence of autoimmune comorbidities, infectious stigma, and raised levels of inflammatory markers in a significant subset of patients. A better understanding of the immune dysfunction in OCD may allow stratifying the patients in order to design personalized pharmaco/psychotherapeutic strategies. RECENT FINDINGS A persistent low-grade inflammation involving both innate and adaptive immune system with coexisting autoimmune morbidities and stigma of infectious events has been prominently observed in OCD. Hence, specific treatments targeting inflammation/infection are a feasible alternative in OCD. This review highlights that OCD is associated with low-grade inflammation, neural antibodies, and neuro-inflammatory and auto-immune disorders. In some subset of OCD patients, autoimmunity is likely triggered by specific bacterial, viral, or parasitic agents with overlapping surface epitopes in CNS. Hence, subset-profiling in OCD is warranted to benefit from distinct immune-targeted treatment modalities.
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Affiliation(s)
- Mona Gerentes
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Antoine Pelissolo
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.,Faculté de médecine, UPEC, Université Paris-Est, 94000, Créteil, France
| | | | - Ryad Tamouza
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Nora Hamdani
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France. .,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.
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24
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Cunningham MW. Molecular Mimicry, Autoimmunity, and Infection: The Cross-Reactive Antigens of Group A Streptococci and their Sequelae. Microbiol Spectr 2019; 7:10.1128/microbiolspec.gpp3-0045-2018. [PMID: 31373269 PMCID: PMC6684244 DOI: 10.1128/microbiolspec.gpp3-0045-2018] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Indexed: 12/20/2022] Open
Abstract
The group A streptococci are associated with a group of diseases affecting the heart, brain, and joints that are collectively referred to as acute rheumatic fever. The streptococcal immune-mediated sequelae, including acute rheumatic fever, are due to antibody and cellular immune responses that target antigens in the heart and brain as well as the group A streptococcal cross-reactive antigens as reviewed in this article. The pathogenesis of acute rheumatic fever, rheumatic heart disease, Sydenham chorea, and other autoimmune sequelae is related to autoantibodies that are characteristic of autoimmune diseases and result from the immune responses against group A streptococcal infection by the host. The sharing of host and streptococcal epitopes leads to molecular mimicry between the streptococcal and host antigens that are recognized by the autoantibodies during the host response. This article elaborates on the discoveries that led to a better understanding of the pathogenesis of disease and provides an overview of the history and the most current thought about the immune responses against the host and streptococcal cross-reactive antigens in group A streptococcal sequelae.
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Affiliation(s)
- Madeleine W Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
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25
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A Pediatric Infectious Disease Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated With Streptococcal Infection and Pediatric Acute-onset Neuropsychiatric Syndrome. Pediatr Infect Dis J 2019; 38:706-709. [PMID: 30747831 DOI: 10.1097/inf.0000000000002295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Hesselmark E, Bejerot S. Clinical features of paediatric acute-onset neuropsychiatric syndrome: findings from a case- control study. BJPsych Open 2019; 5:e25. [PMID: 31068234 PMCID: PMC6401534 DOI: 10.1192/bjo.2019.10] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Paediatric acute-onset neuropsychiatric syndrome (PANS), an umbrella term that includes PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is suggested to be a psychiatric disorder of autoimmune aetiology. PANS is characterised by an acute onset of obsessive-compulsive disorder or restricted eating with multiple comorbid symptoms. The specificity of the PANS criteria is not fully understood.AimsTo describe a cohort of patients with PANS and to determine if PANS features relating to symptoms, onset and course are more common in PANS than in other psychiatric conditions. METHOD A case-control study comparing patients with interview-confirmed PANS with patients with suspected PANS and patients with a psychiatric condition but with no suspicion of PANS. Validated and non-validated measures of symptoms, onset and episodic course were used. RESULTS Illness in patients with interview-confirmed PANS featured an episodic course and multiple symptoms present at onset compared with the psychiatric controls. However, individuals with interview-confirmed PANS did not present a specific symptom profile. CONCLUSIONS PANS may be a distinct clinical entity featuring an acute onset, an episodic course and multiple symptoms at onset.Declaration of interestNone.
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Affiliation(s)
- Eva Hesselmark
- PhD Student, Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet; and Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Susanne Bejerot
- Professor, School of Medical Sciences, Örebro University; University Health Care Research Center, Faculty of Medicine and Health, Örebro University; and Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Sweden
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27
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Schrag A, Martino D, Apter A, Ball J, Bartolini E, Benaroya-Milshtein N, Buttiglione M, Cardona F, Creti R, Efstratiou A, Gariup M, Georgitsi M, Hedderly T, Heyman I, Margarit I, Mir P, Moll N, Morer A, Müller N, Müller-Vahl K, Münchau A, Orefici G, Plessen KJ, Porcelli C, Paschou P, Rizzo R, Roessner V, Schwarz MJ, Steinberg T, Tagwerker Gloor F, Tarnok Z, Walitza S, Dietrich A, Hoekstra PJ. European Multicentre Tics in Children Studies (EMTICS): protocol for two cohort studies to assess risk factors for tic onset and exacerbation in children and adolescents. Eur Child Adolesc Psychiatry 2019; 28:91-109. [PMID: 29982875 PMCID: PMC6349795 DOI: 10.1007/s00787-018-1190-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022]
Abstract
Genetic predisposition, autoimmunity and environmental factors [e.g. pre- and perinatal difficulties, Group A Streptococcal (GAS) and other infections, stress-inducing events] might interact to create a neurobiological vulnerability to the development of tics and associated behaviours. However, the existing evidence for this relies primarily on small prospective or larger retrospective population-based studies, and is therefore still inconclusive. This article describes the design and methodology of the EMTICS study, a longitudinal observational European multicentre study involving 16 clinical centres, with the following objectives: (1) to investigate the association of environmental factors (GAS exposure and psychosocial stress, primarily) with the onset and course of tics and/or obsessive-compulsive symptoms through the prospective observation of at-risk individuals (ONSET cohort: 260 children aged 3-10 years who are tic-free at study entry and have a first-degree relative with a chronic tic disorder) and affected individuals (COURSE cohort: 715 youth aged 3-16 years with a tic disorder); (2) to characterise the immune response to microbial antigens and the host's immune response regulation in association with onset and exacerbations of tics; (3) to increase knowledge of the human gene pathways influencing the pathogenesis of tic disorders; and (4) to develop prediction models for the risk of onset and exacerbations of tic disorders. The EMTICS study is, to our knowledge, the largest prospective cohort assessment of the contribution of different genetic and environmental factors to the risk of developing tics in putatively predisposed individuals and to the risk of exacerbating tics in young individuals with chronic tic disorders.
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Affiliation(s)
- Anette Schrag
- 0000000121901201grid.83440.3bDepartment of Clinical Neurosciences, UCL Institute of Neurology, University College London, London, UK
| | - Davide Martino
- 0000 0004 1936 7697grid.22072.35Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Alan Apter
- 0000 0004 1937 0546grid.12136.37Child and Adolescent Psychiatry Department, Schneider Children’s Medical Center of Israel, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Petah-Tikva, Israel
| | - Juliane Ball
- 0000 0004 1937 0650grid.7400.3Clinic of Child and Adolescent Psychiatry and Psychotherapy, University of Zurich, Zurich, Switzerland
| | | | - Noa Benaroya-Milshtein
- 0000 0004 1937 0546grid.12136.37Child and Adolescent Psychiatry Department, Schneider Children’s Medical Center of Israel, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Petah-Tikva, Israel
| | - Maura Buttiglione
- 0000 0001 0120 3326grid.7644.1Department of Biological Sciences and Human Oncology, Medical School, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Cardona
- grid.7841.aDepartment of Human Neurosciences, University La Sapienza of Rome, Rome, Italy
| | - Roberta Creti
- 0000 0000 9120 6856grid.416651.1Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Androulla Efstratiou
- 0000 0004 5909 016Xgrid.271308.fWHO Global Collaborating Centre for Reference and Research on Diphtheria and Streptococcal Infections, Reference Microbiology, Directorate National Infection Service, Public Health England, London, UK
| | - Maria Gariup
- 0000 0004 1937 0247grid.5841.8University of Barcelona, Barcelona, Spain ,Intensive Inpatient Unit, Copenhagen Psychiatric Center, Copenhagen, Denmark
| | - Marianthi Georgitsi
- 0000 0001 2170 8022grid.12284.3dDepartment of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupoli, Greece ,0000000109457005grid.4793.9Department of Medicine, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Tammy Hedderly
- 0000 0004 5345 7223grid.483570.dEvelina London Children’s Hospital GSTT, Kings Health Partners AHSC, London, UK
| | - Isobel Heyman
- 0000000121901201grid.83440.3bGreat Ormond Street Hospital for Children, UCL Institute of Child Health, London, UK
| | | | - Pablo Mir
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clinica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - Natalie Moll
- 0000 0004 1936 973Xgrid.5252.0Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Astrid Morer
- 0000 0000 9635 9413grid.410458.cDepartment of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciences, Hospital Clinic Universitari, Barcelona, Spain ,grid.10403.36Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain ,0000 0000 9314 1427grid.413448.eCentro de Investigacion en Red de Salud Mental (CIBERSAM), Instituto Carlos III, Madrid, Spain
| | - Norbert Müller
- 0000 0004 1936 973Xgrid.5252.0Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany ,Marion von Tessin Memory-Zentrum gGmbH, Munich, Germany
| | - Kirsten Müller-Vahl
- 0000 0000 9529 9877grid.10423.34Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Alexander Münchau
- 0000 0001 0057 2672grid.4562.5Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Graziella Orefici
- 0000 0000 9120 6856grid.416651.1Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Kerstin J. Plessen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark and University of Copenhagen, Copenhagen, Denmark ,0000 0001 2165 4204grid.9851.5Service of Child and Adolescent Psychiatry, Department of Psychiatry, University Medical Center, University of Lausanne, Lausanne, Switzerland
| | - Cesare Porcelli
- Azienda Sanitaria Locale di Bari, Mental Health Department, Child and Adolescent Neuropsychiatry Service of Bari Metropolitan Area, Bari, Italy
| | - Peristera Paschou
- 0000 0004 1937 2197grid.169077.eDepartment of Biological Sciences, Purdue University, West Lafayette, USA
| | - Renata Rizzo
- 0000 0004 1757 1969grid.8158.4Child Neuropsychiatry Section, Department of Clinical and Experimental Medicine, School of Medicine, Catania University, Catania, Italy
| | - Veit Roessner
- 0000 0001 2111 7257grid.4488.0Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Markus J. Schwarz
- 0000 0004 1936 973Xgrid.5252.0Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Tamar Steinberg
- 0000 0004 1937 0546grid.12136.37Child and Adolescent Psychiatry Department, Schneider Children’s Medical Center of Israel, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Petah-Tikva, Israel
| | - Friederike Tagwerker Gloor
- 0000 0004 1937 0650grid.7400.3Clinic of Child and Adolescent Psychiatry and Psychotherapy, University of Zurich, Zurich, Switzerland
| | - Zsanett Tarnok
- Vadaskert Child and Adolescent Psychiatric Hospital, Budapest, Hungary
| | - Susanne Walitza
- 0000 0004 1937 0650grid.7400.3Clinic of Child and Adolescent Psychiatry and Psychotherapy, University of Zurich, Zurich, Switzerland
| | - Andrea Dietrich
- 0000 0004 0407 1981grid.4830.fDepartment of Child and Adolescent Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Pieter J. Hoekstra
- 0000 0004 0407 1981grid.4830.fDepartment of Child and Adolescent Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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28
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Lamothe H, Baleyte JM, Smith P, Pelissolo A, Mallet L. Individualized Immunological Data for Precise Classification of OCD Patients. Brain Sci 2018; 8:E149. [PMID: 30096863 PMCID: PMC6119917 DOI: 10.3390/brainsci8080149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Pauline Smith
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
| | - Antoine Pelissolo
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- INSERM, U955, Team 15, 94000 Créteil, France.
| | - Luc Mallet
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, 1202 Geneva, Switzerland.
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29
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A Pediatric Neurology Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute-Onset Neuropsychiatric Syndrome. J Pediatr 2018; 199:243-251. [PMID: 29793872 DOI: 10.1016/j.jpeds.2018.04.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/25/2018] [Accepted: 04/17/2018] [Indexed: 12/21/2022]
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30
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Abstract
The Jones criteria of 2 major criteria or 1 major plus 2 minor criteria that have been classically used to establish the diagnosis have been significantly modified in 2015 by the American Heart Association. The criteria now include the utilization of echocardiography and Doppler color flow mapping as diagnostic tools for carditis, along with defining criteria in relation to overall population risk, delineating low- versus moderate-high risk populations. Monoarthritis and polyarthralgia are now major criteria for moderate- to high-risk groups.
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Frick L, Rapanelli M, Jindachomthong K, Grant P, Leckman JF, Swedo S, Williams K, Pittenger C. Differential binding of antibodies in PANDAS patients to cholinergic interneurons in the striatum. Brain Behav Immun 2018; 69:304-311. [PMID: 29233751 PMCID: PMC5857467 DOI: 10.1016/j.bbi.2017.12.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/07/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022] Open
Abstract
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, or PANDAS, is a syndrome of acute childhood onset of obsessive-compulsive disorder and other neuropsychiatric symptoms in the aftermath of an infection with Group A beta-hemolytic Streptococcus (GABHS). Its pathophysiology remains unclear. PANDAS has been proposed to result from cross-reactivity of antibodies raised against GABHS with brain antigens, but the targets of these antibodies are unclear and may be heterogeneous. We developed an in vivo assay in mice to characterize the cellular targets of antibodies in serum from individuals with PANDAS. We focus on striatal interneurons, which have been implicated in the pathogenesis of tic disorders. Sera from children with well-characterized PANDAS (n = 5) from a previously described clinical trial (NCT01281969), and matched controls, were infused into the striatum of mice; antibody binding to interneurons was characterized using immunofluorescence and confocal microscopy. Antibodies from children with PANDAS bound to ∼80% of cholinergic interneurons, significantly higher than the <50% binding seen with matched healthy controls. There was no elevated binding to two different populations of GABAergic interneurons (PV and nNOS-positive), confirming the specificity of this phenomenon. Elevated binding to cholinergic interneurons resolved in parallel with symptom improvement after treatment with intravenous immunoglobulin. Antibody-mediated dysregulation of striatal cholinergic interneurons may be a locus of pathology in PANDAS. Future clarification of the functional consequences of this specific binding may identify new opportunities for intervention in children with this condition.
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Affiliation(s)
| | | | | | - Paul Grant
- Pediatrics and Developmental Neuroscience Branch, National Institute
of Mental Health
| | - James F. Leckman
- Department of Psychology, Yale University,Child Study Center, Yale University
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute
of Mental Health
| | - Kyle Williams
- Department of Psychiatry, Yale University, United States; Child Study Center, Yale University, United States; Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, United States.
| | - Christopher Pittenger
- Department of Psychiatry, Yale University, United States; Department of Psychology, Yale University, United States; Child Study Center, Yale University, United States; Interdepartmental Neuroscience Program, Yale University, United States.
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Shores DR, Everett AD. Children as Biomarker Orphans: Progress in the Field of Pediatric Biomarkers. J Pediatr 2018; 193:14-20.e31. [PMID: 29031860 PMCID: PMC5794519 DOI: 10.1016/j.jpeds.2017.08.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Darla R Shores
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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Hesselmark E, Bejerot S. Biomarkers for diagnosis of Pediatric Acute Neuropsychiatric Syndrome (PANS) – Sensitivity and specificity of the Cunningham Panel. J Neuroimmunol 2017; 312:31-37. [DOI: 10.1016/j.jneuroim.2017.09.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/10/2017] [Accepted: 09/05/2017] [Indexed: 11/16/2022]
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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. 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: 67] [Impact Index Per Article: 9.6] [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.
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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
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Affiliation(s)
- Harvey S Singer
- Professor of Neurology and Pediatric, Johns Hopkins University School of Medicine, Rubenstein Child Health Building, Baltimore, Maryland.
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Singer HS. Autoantibody-Associated Movement Disorders in Children: Proven and Proposed. Semin Pediatr Neurol 2017; 24:168-179. [PMID: 29103424 DOI: 10.1016/j.spen.2017.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Movement disorders secondary to autoantibodies in children represent a rapidly expanding group of conditions. Once considered to be limited to poststreptococcal Sydenham's chorea or rare cases of childhood systemic lupus erythematosus, a variety of antibody-related movement abnormalities are now seen as part of noninfectious autoimmune encephalitis or within an expanding list of postinfectious disorders. In this article, several proposed autoantibody-mediated movement disorders in children are reviewed. In each one, there is a hypothesized antibody biomarker that is believed to be pathogenic and cause the clinical symptoms. As will be discussed, in some, such as anti-NMDA receptor encephalitis, the strength of supporting evidence is strong. In others, antibodies have been identified, but their role as the pathophysiological mechanism remains undetermined. Lastly, there are proposed disorders, such as PANDAS, that are controversial on both a clinical and autoimmune basis.
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Affiliation(s)
- Harvey S Singer
- Departments of Neurology and Pediatrics, Johns Hopkins University, Baltimore MD.
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Chiarello F, Spitoni S, Hollander E, Matucci Cerinic M, Pallanti S. An expert opinion on PANDAS/PANS: highlights and controversies. Int J Psychiatry Clin Pract 2017; 21:91-98. [PMID: 28498087 DOI: 10.1080/13651501.2017.1285941] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES 'Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections' (PANDAS) identified a unique subgroup of patients with abrupt onset of obsessive compulsive disorder (OCD) symptoms clinically related to Streptococcus infection and accompanied by neuropsychological and motor symptoms. After almost 20 years, PANDAS has not been accepted as distinct disorder and new criteria for paediatric acute-onset neuropsychiatric syndrome (PANS) have been replaced it, highlighting the fact that several agents rather than only Streptococcus might be involved. METHODS Extensive review of the PANDAS/PANS literature was performed on PubMed. RESULTS Although antibiotics have been reported to be effective for acute and prophylactic phases in several uncontrolled studies and non-steroidal anti-inflammatory drugs (NSAID) are used during exacerbations, clinical multicenter trials are still missing. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT) are still the first line of recommendation for acute onset OCD spectrum. Immunological therapies should be restricted to a few cases. CONCLUSIONS While PANDAS has found no confirmation as a distinct syndrome, and it is not presented in DSM-5, patients with acute onset OCD spectrum, neurocognitive and motor symptoms should be evaluated for inflammatory, infective, immunological and metabolic abnormalities with a comprehensive diagnostic algorithm.
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Affiliation(s)
| | - Silvia Spitoni
- a Department of Neurofarba , University of Florence , Florence , Italy
| | - Eric Hollander
- b Department of Psychiatry , Icahn School of Medicine , NY , USA.,c Department of Psychiatry and Behavioral Sciences , Albert Einstein College of Medicine , NY , USA
| | - Marco Matucci Cerinic
- d Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Stefano Pallanti
- a Department of Neurofarba , University of Florence , Florence , Italy.,e Institute of Neuroscience , Florence , Italy
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Williams KA, Swedo SE, Farmer CA, Grantz H, Grant PJ, D'Souza P, Hommer R, Katsovich L, King RA, Leckman JF. Randomized, Controlled Trial of Intravenous Immunoglobulin for Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections. J Am Acad Child Adolesc Psychiatry 2016; 55:860-867.e2. [PMID: 27663941 DOI: 10.1016/j.jaac.2016.06.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/15/2016] [Accepted: 07/28/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are hypothesized to occur as a result of cross-reactive antibodies produced in response to group A streptococcal infections. Previous research suggests that immunomodulatory therapies, such as intravenous immunoglobulin (IVIG), may lead to rapid and sustained symptom improvement in patients with PANDAS. METHOD A total of 35 children meeting criteria for PANDAS and moderate to severe obsessive-compulsive disorder (OCD) were enrolled in a randomized-entry, double-blind, placebo-controlled, 6-week trial of IVIG (1 g/kg/day on 2 consecutive days), followed by optional open-label treatment for nonresponders, with follow-up at 12 and 24 weeks. Primary outcome measures were the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Clinical Global Impressions-Improvement (CGI-I) rating. "Responders" were defined, a priori, by a ≥ 30% decrease in CY-BOCS total score, and a "much" or "very much" improved rating on CGI-I. RESULTS During the double-blind phase, the mean decrease in CY-BOCS score was 24% ± 31% in the IVIG group (n = 17) and 12% ± 27% in the placebo group (n = 18), with six responders in the IVIG group (35%) versus four (22%) in the placebo group; these differences were not statistically significant. Twenty-four participants met criteria for nonresponse to double-blind infusion and received open-label IVIG at week 6. Among all participants, the mean CY-BOCS improvement from baseline was 55% ± 33% at week 12 and 62% ± 33% at week 24. CONCLUSION IVIG was safe and well tolerated. Between-group differences were smaller than anticipated, and the double-blind comparison failed to demonstrate superiority of IVIG over placebo. The observed open-label improvements indicate that future trials would benefit from larger sample sizes designed in part to aid in the identification of biomarkers predictive of a positive response to immunotherapy. Future investigations focused on the natural history of PANDAS are also warranted. Clinical trial registration information-Intravenous Immunoglobulin for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections); http://clinicaltrials.gov/; NCT01281969ZIAMH002666.
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Affiliation(s)
- Kyle A Williams
- Child Study Center at Yale University School of Medicine, New Haven, CT; Pediatric Neuropsychiatry and Immunology Program at Massachusetts General Hospital, Boston, MA
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD.
| | - Cristan A Farmer
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Heidi Grantz
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - Paul J Grant
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Precilla D'Souza
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Rebecca Hommer
- Pediatrics and Developmental Neuroscience Program of the National Institute of Mental Health, Bethesda, MD
| | - Liliya Katsovich
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - Robert A King
- Child Study Center at Yale University School of Medicine, New Haven, CT
| | - James F Leckman
- Child Study Center at Yale University School of Medicine, New Haven, CT
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Cutforth T, DeMille MM, Agalliu I, Agalliu D. CNS autoimmune disease after Streptococcus pyogenes infections: animal models, cellular mechanisms and genetic factors. FUTURE NEUROLOGY 2016; 11:63-76. [PMID: 27110222 DOI: 10.2217/fnl.16.4] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Streptococcus pyogenes infections have been associated with two autoimmune diseases of the CNS: Sydenham's chorea (SC) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS). Despite the high frequency of pharyngeal streptococcus infections among children, only a small fraction develops SC or PANDAS. This suggests that several factors in combination are necessary to trigger autoimmune complications: specific S. pyogenes strains that induce a strong immune response toward the host nervous system; genetic susceptibility that predispose children toward an autoimmune response involving movement or tic symptoms; and multiple infections of the throat or tonsils that lead to a robust Th17 cellular and humoral immune response when untreated. In this review, we summarize the evidence for each factor and propose that all must be met for the requisite neurovascular pathology and behavioral deficits found in SC/PANDAS.
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Affiliation(s)
- Tyler Cutforth
- Department of Neurology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA
| | - Mellissa Mc DeMille
- Department of Pediatrics, Yale Child Health Research Center, Yale University School of Medicine, 464 Congress Avenue, Suite S208, New Haven, CT 06519, USA
| | - Ilir Agalliu
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave., Room 1315-B, Bronx, NY 10461, USA
| | - Dritan Agalliu
- Department of Neurology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA; Departments of Pathology & Cell Biology & Pharmacology, Columbia University Medical Center, 650 West 168 Street, Room 310E, New York, NY 10032, USA
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Eftimiadi C, Eftimiadi G, Vinai P. Staphylococcus aureus Colonization Modulates Tic Expression and the Host Immune Response in a Girl with Tourette Syndrome. Front Psychiatry 2016; 7:31. [PMID: 27014098 PMCID: PMC4789548 DOI: 10.3389/fpsyt.2016.00031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/24/2016] [Indexed: 11/13/2022] Open
Abstract
A 9-year-old girl with Tourette syndrome (TS) and increased antibody levels against Streptococcus pyogenes was monitored longitudinally for the presence of nasopharyngeal bacteria, specific antibody titers, and autoimmunity directed against brain antigens. Microbiological monitoring indicated that the child was an intermittent Staphylococcus aureus nasopharyngeal carrier. Clinical improvements in motor tic frequency and severity were observed during the S. aureus colonization phase and were temporally correlated with the downregulation of anti-streptococcal and anti-D1/D2 dopamine receptor antibody production. After decolonization, clinical conditions reverted to the poor scores previously observed, suggesting a possible role of the immune response in bacterial clearance as a trigger of symptom recrudescence. These findings imply that a cause-effect relationship exists between S. aureus colonization and tic improvement, as well as between bacterial decolonization and tic exacerbation. Understanding the impact of S. aureus on the host adaptive immune response and the function of autoantibodies in the pathogenesis of TS may alter approaches for managing autoimmune neuropsychiatric and tic disorders.
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Affiliation(s)
- Costantino Eftimiadi
- Medicina Generale Convenzionata - ASL CN1, Carrù, Italy; GNOSIS Research Group NPO, Magliano Alpi, Italy
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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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Singer HS. PANDAS: The Need to Use Definitive Diagnostic Criteria. Tremor Other Hyperkinet Mov (N Y) 2015; 5:327. [PMID: 26196028 PMCID: PMC4502346 DOI: 10.7916/d8pn94rq] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In Response to: Helm CE, Blackwood RA. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS): Experience at a tertiary referral center. Tremor Other Hyperkinet Mov. 2015; 5. doi: 10.7916/D8348JCX.
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Affiliation(s)
- Harvey S. Singer
- Departments of Neurology and Pediatrics, The Johns Hopkins Hospital, Baltimore, MD, USA,To whom correspondence should be addressed. E-mail:
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