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O'Dor SL, Zagaroli JS, Belisle RM, Hamel MA, Downer OM, Homayoun S, Williams KA. The COVID-19 pandemic and children with PANS/PANDAS: an evaluation of symptom severity, telehealth, and vaccination hesitancy. Child Psychiatry Hum Dev 2024; 55:327-335. [PMID: 35930178 PMCID: PMC9361990 DOI: 10.1007/s10578-022-01401-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
The current study assessed the impact of the COVID-19 pandemic on children with PANS/PANDAS, a condition characterized by sudden-onset obsessive-compulsive, tic, or restrictive eating symptoms following infection. We conducted an anonymous survey between February and June 2021 of 254 self-reported caregivers of minors with PANS/PANDAS. Caregivers answered questions regarding PANS/PANDAS symptoms, telehealth care, and intention to vaccinate their child against COVID-19. PANS/PANDAS symptoms during COVID-19 infections were assessed when applicable. Children's OCD symptoms and coercive behaviors towards caregivers, along with the caregivers' mental health, relationship satisfaction, and burden, were assessed using standardized questionnaires. A majority of respondents endorsed a negative impact on their child's friendships, relationships with extended family, hobbies, and academic skills due to the pandemic. Children with suspected or diagnosed COVID-19 experienced new or worsened psychiatric symptoms, particularly mood lability, OCD, and anxiety. Telehealth care was the preferred treatment modality if the child had mild symptoms of PANS/PANDAS. A majority of caregivers reported high levels of relationship dissatisfaction and caregiver burden. As expected, these data suggest an overall negative impact of the COVID-19 pandemic on children with PANS/PANDAS and their caregivers.
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Affiliation(s)
- Sarah L O'Dor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
- Yawkey Outpatient Center, Massachusetts General Hospital, Suite 6A, 55 Fruit St, 02114, Boston, MA, USA.
| | - J S Zagaroli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - R M Belisle
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - M A Hamel
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - O M Downer
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - S Homayoun
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - K A Williams
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Bernstein GA, Khan MH, Freese RL, Manko C, Silverman M, Ahmed S, Farhadian B, Ma M, Thienemann M, Murphy TK, Frankovich J. Psychometric Properties of the PANS 31-Item Symptom Rating Scale. J Child Adolesc Psychopharmacol 2024; 34:157-162. [PMID: 38536004 DOI: 10.1089/cap.2023.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by sudden onset of obsessive-compulsive disorder and/or eating restriction with associated neuropsychiatric symptoms from at least two of seven categories. The PANS 31-Item Symptom Rating Scale (PANS Rating Scale) was developed to identify and measure the severity of PANS symptoms. The objective of this study was to define the psychometric properties of the PANS Rating Scale. Methods: Children with PANS (N = 135) and their parents participated. Parents completed the PANS Rating Scale and other scales on Research Electronic Data Capture. The PANS Rating Scale includes 31 items that are rated on a Likert scale from 0 = none to 4 = extreme. Pearson's correlations were run between the PANS Total score and scores on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Yale Global Tic Severity Scale (YGTSS), Modified Overt Aggression Scale (MOAS), Columbia Impairment Scale (CIS), PANS Global Impairment Score (GIS), and Children's Global Assessment Scale (CGAS). Results: Convergent validity was supported by significant correlations between the PANS Total and scores on the CY-BOCS, YGTSS, MOAS, CIS, GIS, and CGAS. The largest correlations were with measures of functional impairment: PANS Total and CIS (r = 0.81) and PANS Total and GIS (r = 0.74). Cronbach's alpha was 0.89 which demonstrates strong internal consistency of the 31 items. PANS Total score was significantly higher in children in a flare of their neuropsychiatric symptoms compared to children who were not in a flare. Conclusions: This study provides preliminary support for the PANS Rating Scale as a valid research instrument with good internal consistency. The PANS Rating Scale appears to be a useful measure for assessing children with PANS.
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Affiliation(s)
- Gail A Bernstein
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Maroof H Khan
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rebecca L Freese
- Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cindy Manko
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sana Ahmed
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Bahare Farhadian
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Meiqian Ma
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tanya K Murphy
- Department of Pediatrics, University of South Florida, St Petersburg, Florida, USA
| | - Jennifer Frankovich
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
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Wells L, O'Hara N, Frye RE, Hullavard N, Smith E. Folate Receptor Alpha Autoantibodies in the Pediatric Acute-Onset Neuropsychiatric Syndrome ( PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Population. J Pers Med 2024; 14:166. [PMID: 38392599 PMCID: PMC10890663 DOI: 10.3390/jpm14020166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
The folate receptor alpha autoantibodies (FRAAs) are associated with cerebral folate deficiency (CFD) and autism spectrum disorder (ASD). Both of these syndromes have overlapping characteristics with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS). Thus, we propose that the FRAAs may contribute to the symptomatology of PANS/PANDAS. To test this hypothesis, 1 mL of serum from 47 patients (age range = 6-18 years old) clinically diagnosed with PANS/PANDAS was sent to Vascular Strategies (Plymouth Meeting, PA, USA) for analysis of FRAAs. Moreover, 63.8% of PANS/PANDAS patients (male = 15; female = 15) were found to have either the blocking and/or blinding FRAAs, with 25 (83.3%; male = 14; female = 11) having binding FRAAs, two (6.7%; all female = 2) having blocking FRAAs, and 3 (10%; male = 1; female = 2) having both binding and blocking. Furthermore, surprisingly, ASD was associated with a 0.76 lower binding titer (p = 0.02), and severe tics were associated with a 0.90 higher binding titer (p = 0.01). A case of a FRAA-positive patient is provided to illustrate that a treatment plan including leucovorin can result in symptom improvement in patients with PANS/PANDAS who are FRAA-positive. These data, for the first time, demonstrate that PANS/PANDAS is associated with FRAAs and suggest folate metabolism abnormalities may contribute to PANS/PANDAS symptomatology. Further studies investigating the therapeutic nature of leucovorin in the treatment of PANS/PANDAS are needed. Such studies may open up an alternative, safe, and well-tolerated treatment for those with the PANS/PANDAS diagnosis.
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Affiliation(s)
| | - Nancy O'Hara
- Nancy O'Hara and Associates LLC, Wilton, CT 06897, USA
| | - Richard E Frye
- Autism Discovery and Treatment Foundation, Phoenix, AZ 85050, USA
| | | | - Erica Smith
- Natural Pediatrics of CT, Stamford, CT 06905, USA
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Leonardi L, Lorenzetti G, Carsetti R, Piano Mortari E, Guido CA, Zicari AM, Förster-Waldl E, Loffredo L, Duse M, Spalice A. Immunological characterization of an Italian PANDAS cohort. Front Pediatr 2024; 11:1216282. [PMID: 38239595 PMCID: PMC10794562 DOI: 10.3389/fped.2023.1216282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/16/2023] [Indexed: 01/22/2024] Open
Abstract
This cross-sectional study aimed to contribute to the definition of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) pathophysiology. An extensive immunological assessment has been conducted to investigate both immune defects, potentially leading to recurrent Group A β-hemolytic Streptococcus (GABHS) infections, and immune dysregulation responsible for a systemic inflammatory state. Twenty-six PANDAS patients with relapsing-remitting course of disease and 11 controls with recurrent pharyngotonsillitis were enrolled. Each subject underwent a detailed phenotypic and immunological assessment including cytokine profile. A possible correlation of immunological parameters with clinical-anamnestic data was analyzed. No inborn errors of immunity were detected in either group, using first level immunological assessments. However, a trend toward higher TNF-alpha and IL-17 levels, and lower C3 levels, was detected in the PANDAS patients compared to the control group. Maternal autoimmune diseases were described in 53.3% of PANDAS patients and neuropsychiatric symptoms other than OCD and tics were detected in 76.9% patients. ASO titer did not differ significantly between the two groups. A possible correlation between enduring inflammation (elevated serum TNF-α and IL-17) and the persistence of neuropsychiatric symptoms in PANDAS patients beyond infectious episodes needs to be addressed. Further studies with larger cohorts would be pivotal to better define the role of TNF-α and IL-17 in PANDAS pathophysiology.
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Affiliation(s)
- Lucia Leonardi
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giulia Lorenzetti
- Department of Pediatrics, University of Rome Tor Vergata, Rome, Italy
| | - Rita Carsetti
- B Cell Physiopathology Unit, Immunology Research Area, Bambino Gesù Children Hospital, Rome, Italy
| | - Eva Piano Mortari
- B Cell Physiopathology Unit, Immunology Research Area, Bambino Gesù Children Hospital, Rome, Italy
| | - Cristiana Alessia Guido
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Anna Maria Zicari
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Elisabeth Förster-Waldl
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics & Adolescent Medicine, Center for Congenital Immunodeficiencies, Medical University of Vienna, Vienna, Austria
| | - Lorenzo Loffredo
- Department of Clinical, Internal Medicine, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marzia Duse
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alberto Spalice
- Department of Maternal, Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
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Schön UK. Young adults' experiences of living with paediatric acute-onset neuropsychiatric syndrome. An interview study. Int J Qual Stud Health Well-being 2023; 18:2267268. [PMID: 37816175 PMCID: PMC10566402 DOI: 10.1080/17482631.2023.2267268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023] Open
Abstract
AIM This article explores experiential knowledge of living with paediatric acute-onset neuropsychiatric syndrome (PANS), and the factors that are associated with perceived good care. METHODS Ten people with lived experience of PANS participated, five women and five men aged 19-34. Semi-structured interviews were used to explore their experience of living with PANS and their encounters with healthcare. Thematic analysis was carried out to identify central themes in the transcribed interviews. RESULTS The study revealed a group of young adults living fairly isolated lives, dependent on care from relatives. To them, the illness was a tangible presence. They perceived a lack of knowledge among healthcare staff on PANS in healthcare, and negative consequences linked to this. In addition, their experience-based knowledge of their own illness is devalued in healthcare encounters. A feeling of being pushed around in healthcare, without anyone taking responsibility for the treatment, emerged in the interviews. The participants emphasized the need for increased knowledge among staff to identify PANS and be able to offer effective treatment. CONCLUSION There is a need to increase the knowledge about PANS in healthcare and to coordinating care between neurology, immunology and psychiatry. To be able to offer evidence-based care to children with PANS, in-depth knowledge is needed about aetiology, treatment effects, and user experiences and preferences.
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Affiliation(s)
- Ulla-Karin Schön
- Department of Social Work, Stockholm University, Stockholm, Sweden
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Calaprice-Whitty D, Tang A, Tona J. Factors Associated with Symptom Persistence in PANS: Part I-Access to Care. J Child Adolesc Psychopharmacol 2023; 33:356-364. [PMID: 37902790 DOI: 10.1089/cap.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Objective: Pediatric acute-onset neuropsychiatric syndrome (PANS) presents with abrupt neuropsychiatric symptoms, often after an immunologic trigger. A 2017 survey of 698 subjects found diagnostic delays to be associated with recurrences, suggesting that timely care impacts course. This secondary analysis explores the impact of barriers to care on symptom persistence. Methods: A 146-question online survey gathered history, symptomatology, intervention, and outcome data from subjects with PANS. Multivariate analyses examined associations between symptom persistence over the entire reported disease course, measured as % days symptom-free over reporting periods averaging approximately 4 years, and access-to-care history, reflected in availability of medical expertise and affordability of care. The impacts of time from symptom onset to treatment and effectiveness of initial antibiotics were also examined. Results: Among the 646 subjects analyzed, greater symptom persistence was associated with longer intervals between symptom onset and treatment (F = 4.43, p = 0.002). Thirty-four percent of subjects with the least symptom persistence (>75% symptom-free days), versus 13% of those with the most (symptoms every day), had been diagnosed by the first practitioner seen (likelihood ratio [L-R] χ2 = 36.55, p < 0.0001, for comparison across all groups). Diagnosis and treatment had not been impeded by lack of access to expertise for 52% of subjects with the least persistent symptoms, versus 22% of those with the most (L-R χ2 = 22.47, p < 0.0001). Affordability had not impacted diagnosis and treatment for 76% of subjects with the least persistent symptoms, versus 42% of those with the most (L-R χ2 = 27.83, p < 0.0001). The subjects whose PANS symptoms resolved with antibiotic treatment of the inciting infection experienced less symptom persistence than others (χ2 = 23.27, p = 0.0001). More persistently symptomatic subjects were more likely to have discontinued intravenous immunoglobulin (IVIG) treatment for access-to-care reasons. Conclusions: Unimpeded access to care for PANS is associated with more symptom-free days over reporting periods averaging approximately 4 years. Difficulty reaching expert providers, missed opportunities for diagnoses, and financial limitations may worsen outcomes. Practitioners, particularly primary providers, should adhere to published diagnostic and treatment guidelines promptly upon presentation.
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Affiliation(s)
- Denise Calaprice-Whitty
- Division of Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
- Brain Inflammation Collaborative, Delafield, Wisconsin, USA
| | - Angela Tang
- Division of Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Janice Tona
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
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Calaprice-Whitty D, Tang A, Tona J. Factors Associated with Symptom Persistence in PANS: Part II-Presenting Features, Medical Comorbidities, and IVIG Treatment History. J Child Adolesc Psychopharmacol 2023; 33:365-377. [PMID: 37902971 DOI: 10.1089/cap.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
Objective: Individuals with Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) experience neuropsychiatric symptoms following an infection or other trigger. Although PANS is typically described as relapsing-remitting, a large community-based 2017 study revealed a range of courses. The present study examined clinical predictors of symptom persistence, measured as % days symptom-free, in this same sample. Methods: A 146-question online survey gathered histories (infections and other triggers, medical and developmental comorbidities), symptomatology, interventions, and outcomes (including school functioning) of PANS patients. Multivariate analyses were applied to examine associations between these variables and % days symptom-free across the disease course. Results: Among the 646 subjects included, significant relationships were found between greater symptom persistence and higher rates of medical comorbidities (especially rashes, headaches, chronic sinusitis, frequent diarrhea, and immune deficiencies), developmental diagnoses, and respondent-perceived developmental lags. Subjects with greater symptom persistence were significantly more likely to report PANS exacerbations associated with infections in close contacts, vaccinations, environmental triggers, and exacerbations of comorbidities and were more likely to report PANS recurrences triggered by Epstein Barr Virus, mycoplasma, and sinus infections. More persistent PANS was also associated with significantly higher frequencies of certain symptoms (sleep disturbance, urinary incontinence, muscle pain, brain fog, sensory defensiveness, irritability, and aggression-related symptoms), less effectiveness of intravenous immunoglobulin in combating symptoms, and more difficulty attending school. Conclusions: Our results suggest high symptom persistence in PANS to be associated with more pervasive medical and neuropsychiatric symptoms. Differences in symptom persistence are associated with both intrinsic (e.g., immune competence) and extrinsic (e.g., infections, treatment) factors. Because extrinsic factors are potentially modifiable, it is critical that providers be aware of current guidelines on PANS evaluation and treatment.
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Affiliation(s)
- Denise Calaprice-Whitty
- Division of Rheumatology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California, USA
- Brain Inflammation Collaborative, Delafield, Wisconsin, USA
| | - Angela Tang
- Division of Rheumatology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California, USA
| | - Janice Tona
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
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Wald ER, Eickhoff J, Flood GE, Heinz MV, Liu D, Agrawal A, Morse RP, Raney VM, Veerapandiyan A, Madan JC. Estimate of the incidence of PANDAS and PANS in 3 primary care populations. Front Pediatr 2023; 11:1170379. [PMID: 37808558 PMCID: PMC10551157 DOI: 10.3389/fped.2023.1170379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Objective Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS) and Pediatric Acute-Onset Neuropsychiatric syndrome (PANS) are presumed autoimmune complications of infection or other instigating events. To determine the incidence of these disorders, we performed a retrospective review for the years 2017-2019 at three academic medical centers. Methods We identified the population of children receiving well-child care at each institution. Potential cases of PANS and PANDAS were identified by including children age 3-12 years at the time they received one of five new diagnoses: avoidant/restrictive food intake disorder, other specified eating disorder, separation anxiety disorder of childhood, obsessive-compulsive disorder, or other specified disorders involving an immune mechanism, not elsewhere classified. Tic disorders was not used as a diagnostic code to identify cases. Data were abstracted; cases were classified as PANDAS or PANS if standard definitions were met. Results The combined study population consisted of 95,498 individuals. The majority were non-Hispanic Caucasian (85%), 48% were female and the mean age was 7.1 (SD 3.1) years. Of 357 potential cases, there were 13 actual cases [mean age was 6.0 (SD 1.8) years, 46% female and 100% non-Hispanic Caucasian]. The estimated annual incidence of PANDAS/PANS was 1/11,765 for children between 3 and 12 years with some variation between different geographic areas. Conclusion Our results indicate that PANDAS/PANS is a rare disorder with substantial heterogeneity across geography and time. A prospective investigation of the same question is warranted.
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Affiliation(s)
- Ellen R. Wald
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jens Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Grace E. Flood
- Medical Director Clinical Analytics and Reporting, University of Wisconsin, Madison, WI, United States
| | - Michael V. Heinz
- Department of Pediatrics, Children’s Hospital at Dartmouth, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Daniel Liu
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Alisha Agrawal
- Department of Pediatrics, Children’s Hospital at Dartmouth, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Richard P. Morse
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Veronica M. Raney
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Aravindhan Veerapandiyan
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Juliette C. Madan
- Department of Pediatrics, Children’s Hospital at Dartmouth, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
- Department of Psychiatry, Children’s Hospital at Dartmouth, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
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Offutt A, Breitschwerdt EB. Case report: Substantial improvement of autism spectrum disorder in a child with learning disabilities in conjunction with treatment for poly-microbial vector borne infections. Front Psychiatry 2023; 14:1205545. [PMID: 37663607 PMCID: PMC10473095 DOI: 10.3389/fpsyt.2023.1205545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/03/2023] [Indexed: 09/05/2023] Open
Abstract
Poly-microbial vector-borne infections may have contributed to neuropsychiatric symptoms in a boy diagnosed with autism spectrum disorder. Targeted antimicrobial treatment resulted in substantial improvement in cognitive (such as learning disabilities, focus, concentration) and neurobehavioral (such as oppositional, defiant, anti-social, disordered mood, immaturity, tics) symptoms.
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Affiliation(s)
- Amy Offutt
- Heart and Soul Integrative Health, Marble Falls, TX, United States
| | - Edward B. Breitschwerdt
- Intracellular Pathogens Research Laboratory, Department of Clinical Sciences, and the Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
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10
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Thorsson M, Galazka MA, Hajjari P, Fernell E, Delafield-Butt J, Gillberg C, Johnson M, Åsberg Johnels J, Hadjikhani N. A novel tablet-based motor coordination test performs on par with the Beery VMI subtest and offers superior temporal metrics: findings from children with pediatric acute-onset neuropsychiatric syndrome. Exp Brain Res 2023; 241:1421-1436. [PMID: 37052647 PMCID: PMC10130113 DOI: 10.1007/s00221-023-06612-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Abstract
Neuropsychiatric and neurodevelopmental disorders are often associated with coordination problems. Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) constitutes a specific example of acute and complex symptomatology that includes difficulties with motor control. The present proof-of-concept study aimed at testing a new, bespoke tablet-based motor coordination test named SpaceSwipe, providing fine-grained measures that could be used to follow-up on symptoms evolution in PANS. This test enables computationally precise and objective metrics of motor coordination, taking into account both directional and spatial features continuously. We used SpaceSwipe to assess motor coordination in a group of children with PANS (n = 12, assessed on in total of 40 occasions) and compared it against the motor coordination subtest from the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) 6th edition, traditionally used to follow-up symptomatology. Using a bivariate linear regression, we found that 33 s of the directional offset from tracking a moving target in SpaceSwipe could predict the Beery VMI motor coordination (VMI MC) raw scores (mean absolute error: 1.75 points). Positive correlations between the predicted scores and the VMI MC scores were found for initial testing (radj = 0.87) and for repeated testing (radj = 0.79). With its short administration time and its close prediction to Beery VMI scores, this proof-of-concept study demonstrates the potential for SpaceSwipe as a patient-friendly tool for precise, objective assessment of motor coordination in children with neurodevelopmental or neuropsychiatric disorders.
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Affiliation(s)
- Max Thorsson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden.
- , Gothenburg, Sweden.
| | - Martyna A Galazka
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Parisa Hajjari
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Elisabeth Fernell
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Mats Johnson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Jakob Åsberg Johnels
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Section of Speech and Language Pathology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Nouchine Hadjikhani
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
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12
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Pallanti S, Di Ponzio M. PANDAS/ PANS in the COVID-19 Age: Autoimmunity and Epstein-Barr Virus Reactivation as Trigger Agents? Children (Basel) 2023; 10:648. [PMID: 37189896 PMCID: PMC10136983 DOI: 10.3390/children10040648] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
COVID-19 impacted the entire world's population, frequently resulting in long-lasting neuropsychiatric complications. Furthermore, social distancing, lockdowns and fear for one's personal health worsen individual psychological wellbeing, especially in children and adolescents. Herein, we discuss the results of studies that specifically reported data about the impact of the COVID-19 pandemic or infection on children with Pediatric Acute-Onset Neuropsychiatric Disorders (PANS). Furthermore, we present the cases of five adolescents with PANS whose symptomatology increased following SARS-CoV-2 infection. What emerged from this study was that COVID-19 resulted in the exacerbation of obsessions, tics, anxiety and mood symptoms and decreased wellbeing. Moreover, new symptoms, as well as new PANS cases, are reported to have arisen after COVID-19 infection. Here, we hypothesize that the pathogenic mechanisms of silent viruses, such as the Epstein-Barr virus, are related to neuroinflammation, immune responses and reactivation, with additional roles played by social-isolation-related inflammatory processes. The discussion of PANS, which represents a model of immune-mediated neuropsychiatric manifestations, is particularly relevant, with the aim of uncovering the mechanisms that lead to neuropsychiatric Post-Acute COVID-19 Syndrome (PACS). Prospects for future studies and treatment implications are discussed.
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Affiliation(s)
- Stefano Pallanti
- Department of Psychiatry and Health Sciences, Institute of Neurosciences, 50121 Florence, Italy
- Department of Psychiatry and Behavioural Sciences, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Michele Di Ponzio
- Department of Psychology and Cognitive Studies, Institute of Neurosciences, 50121 Florence, Italy
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13
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Delaney SL, Murray LA, Fallon BA. Neuropsychiatric Symptoms and Tick-Borne Diseases. Curr Top Behav Neurosci 2023; 61:279-302. [PMID: 36512289 DOI: 10.1007/7854_2022_406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
In North America, Lyme disease (LD) is primarily caused by the spirochetal bacterium Borrelia burgdorferi, transmitted to humans by Ixodes species tick bites, at an estimated rate of 476,000 patients diagnosed per year. Acute LD often manifests with flu-like symptoms and an expanding rash known as erythema migrans (EM) and less often with neurologic, neuropsychiatric, arthritic, or cardiac features. Most acute cases of Lyme disease are effectively treated with antibiotics, but 10-20% of individuals may experience recurrent or persistent symptoms. This chapter focuses on the neuropsychiatric aspects of Lyme disease, as these are less widely recognized by physicians and often overlooked. Broader education about the potential complexity, severity, and diverse manifestations of tick-borne diseases is needed.
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Affiliation(s)
- Shannon L Delaney
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA.
| | - Lilly A Murray
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
| | - Brian A Fallon
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
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Younger DS. Pediatric neuropsychiatric disorders with motor and nonmotor phenomena. Handb Clin Neurol 2023; 196:367-387. [PMID: 37620079 DOI: 10.1016/b978-0-323-98817-9.00028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
The concept of pediatric autoimmune neuropsychiatric disorders associated with group A beta-hemolytic streptococcus (PANDAS) has become seminal since first introduced more than two decades ago. At the time of this writing, most neurologists, pediatricians, psychiatrists, and general pediatricians will probably have heard of this association or treated an affected child with PANDAS. The concept of an acute-onset, and typically self-limited, postinfectious autoimmune neuropsychiatric disorder resembling PANDAS manifesting vocal and motor tics and obsessive-compulsive disorder has broadened to other putative microbes and related endogenous and exogenous disease triggers. These disorders with common features of hypometabolism in the medial temporal lobe and hippocampus in brain 18fluorodeoxyglucose positron emission tomography fused to magnetic resonance imaging (FDG PET-MRI), form a spectrum: with the neuropsychiatric disorder Tourette syndrome and PANDAS with its well-defined etiopathogenesis at one end, and pediatric abrupt-onset neuropsychiatric syndrome (PANS), alone or associated with specific bacterial and viral pathogens, at the other end. The designation of PANS in the absence of a specific trigger, as an exclusionary diagnosis, reflects the current problem in nosology.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Spivak NM, Haroon J, Swenson A, Turnbull SA, Dang N, Ganeles M, Price C, Distler M, Nurmi E, Lavretsky H, Bystritsky A. Microbiome in Anxiety and Other Psychiatric Disorders. Med Clin North Am 2023; 107:73-83. [PMID: 36402501 DOI: 10.1016/j.mcna.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Initial studies suggested that the fluctuations in the quantity, variety, and composition of the gut microbiota can significantly affect disease processes. This change in the gut microbiota causing negative health benefits was coined dysbiosis. Initial research focused on gastrointestinal illnesses. However, the gut microbiome was found to affect more than just gastrointestinal diseases. Numerous studies have proven that the gut microbiome can influence neuropsychiatric diseases such as Parkinson's disease, Alzheimer's disease, and multiple sclerosis.
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Affiliation(s)
- Norman M Spivak
- UCLA-Caltech Medical Scientist Training Program; Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA.
| | - Jonathan Haroon
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Andrew Swenson
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Scott A Turnbull
- Department of Internal Medicine, Kirk Kerkorian SOM, UNLV, 4505 South Maryland Parkway, Las Vegas, NV 89154, USA
| | - Nolan Dang
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Matthew Ganeles
- Department of Molecular, Cell and Developmental Biology, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Collin Price
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Margaret Distler
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Erika Nurmi
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
| | - Alexander Bystritsky
- Department of Psychiatry and Biobehavioral Sciences, DGSOM, UCLA, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095, USA
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Efe A. SARS-CoV-2/COVID-19 associated pediatric acute-onset neuropsychiatric syndrome a case report of female twin adolescents. Psychiatry Res Case Rep 2022; 1:100074. [PMID: 36267397 PMCID: PMC9562621 DOI: 10.1016/j.psycr.2022.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/07/2022]
Abstract
“Pediatric acute-onset neuropsychiatric syndrome”, or PANS, is a rare syndrome characterized by an acute onset of obsessive-compulsive disorder (OCD), and/or severely restricted food intake accompanied by a variety of neuropsychiatric symptoms. To our knowledge, this is the first case report of twin adolescents with COVID-19-associated PANS. Dizygotic twin sisters in late teens, with abrupt and acute onset of severely restrictive food intake, weight loss, OCD, anxiety with intermittent auditory and visual hallucinations, depression, attention deficit, and sleep disturbances, simultaneously accompanied by milder neurologic symptoms such as hand tremor, tinnitus, dizziness, headache, and weakness of proximal muscles, were applied to child and adolescent psychiatry clinic. The only relevant agent underlying those neuropsychiatric and somatic complaints was COVID-19, and it was validated with laboratory testing, such as positive IgG titers of SARS-CoV-2 and negative biomarkers for other possible bacterial or viral agents. Generalized epileptic anomaly and a vermian/folial atrophy in the cerebellum were detected in further evaluations. Treatment options consisted of psychotropic agents, antibiotics, antiepileptic, and intravenous immunoglobulin transfusion finely treated the neuropsychiatric symptoms. Clinicians should consider SARS-CoV-2 as a potential agent, when a child presents with abrupt onset, dramatic neuropsychiatric symptoms also consisting of PANS, even in asymptomatic patients or with mild respiratory symptoms.
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Gao J, Chan A, Willett T, Farhadian B, Silverman M, Tran P, Ahmed S, Thienemann M, Frankovich J. Sex and Aggression Characteristics in a Cohort of Patients with Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2022; 32:444-452. [PMID: 35998241 PMCID: PMC9603278 DOI: 10.1089/cap.2021.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective: This study describes for the first time the characteristics by sex of patients with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), including clinical phenotype, treatment, and psychosocial aspects of disease. Methods: This cross-sectional study included 205 consecutive community patients evaluated between January 1, 2012 and March 30, 2019 and compared 87 females with 118 males. Our primary hypothesis was that males would display more aggression, as measured by the Modified Overt Aggression Scale (MOAS) and would be treated with immunotherapy earlier than females. The MOAS began to be administered 5 years into the study period, and 57 of the 205 families completed the MOAS for this study. Results: Our analysis revealed that males had a higher median MOAS score in the first year of clinic when compared with females (median 11, interquartile range [IQR] [4-24] vs. median 3, IQR [1-9]; p = 0.03) and a higher median subscore for physical aggression (median 4, IQR [0-12] vs. median 0, IQR [0-8]; p = 0.05). The median time from PANS symptom onset to first administration of immunotherapy, which did not include nonsteroidal anti-inflammatory drugs or short bursts of oral steroids, was 6.9 years for females and 3.7 years for males (p = 0.20). The two groups did not differ significantly in age of PANS onset, time from onset to clinic entry, other psychiatric symptom measures, or laboratory markers of inflammation. Conclusion: Among patients with PANS, males exhibit more aggressive behavior when compared with females, which may advance the decision to treat with immunotherapy. Scores that capture a more global level of functioning show that despite there being a higher level of aggression in males, female patients with PANS have similar levels of overall impairment.
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Affiliation(s)
- Jaynelle Gao
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Avis Chan
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Theresa Willett
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Bahare Farhadian
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Paula Tran
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Sana Ahmed
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer Frankovich
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA.,Address correspondence to: Jennifer Frankovich, MD, MS, Department of Pediatrics, Stanford University of Medicine, 700 Welch Road, Stanford, CA 94305, USA
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Prosell U, Norman H, Sand A, McAllister A. Infection and speech: Disfluency and other speech symptoms in Pediatric Acute-onset Neuropsychiatric Syndrome. J Commun Disord 2022; 99:106250. [PMID: 35964340 DOI: 10.1016/j.jcomdis.2022.106250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION In the early 20th century a link between infection and speech disfluency was discussed. Recent reports indicate that PANS (Pediatric Acute-onset Neuropsychiatric Syndrome), and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) may be associated with a high incidence of speech disfluency. The present study specifically investigates disfluency and other speech symptoms following onset of PANS and PANDAS. Prevalence of previously reported speech related symptoms vocal tics, selective mutism and "baby talk" is included. The present study also aims to explore possible changes in articulation and intelligibility, distress due to speech impairment, and effect of PANS or PANDAS medication on speech symptoms. METHODS A questionnaire was distributed to caregivers of children with diagnosed or suspected PANS or PANDAS. In total 55 individuals in Sweden were included. RESULTS Onset of speech disfluency in association with PANS or PANDAS was reported by 54.5% of the caregivers. Most frequent disfluency symptoms were higher speech rate, superfluous verbal behavior, verbal blocks and associated motor symptoms. Previous findings of vocal tics, baby talk and mutistic behavior are supported. The present study also exposed previously unreported symptoms such as impaired articulation, reduced intelligibility, reduced speech production and language impairment. Eleven caregivers reported that medical treatment had a positive effect on speech fluency. CONCLUSIONS A connection between PANS and PANDAS and speech disfluency is supported, and a possible link between infection and disfluency is reactualized. Reported disfluency shares several characteristics with stuttering and cluttering, but the caregivers did not consistently associate it with stuttering. The present study also sheds new light on how symptoms of "baby talk", selective mutism and vocal tics might be viewed in this population. In all, the results indicate a substantial impact on speech fluency, speech and language in affected children, reducing quality of life.
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Affiliation(s)
- Una Prosell
- Karolinska Institutet, CLINTEC, Division of Speech-language pathology, Stockholm, Sweden; Autismcenter små barn (the Autism center for small children), Rosenlund Hospital, Tideliusgatan 12, Stockholm, 11869 Sweden.
| | - Hanna Norman
- Karolinska Institutet, CLINTEC, Division of Speech-language pathology, Stockholm, Sweden; Logopedbyrån Dynamica, Hammarby Allé 91, Stockholm, 120 63 Sweden.
| | - Anders Sand
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Sweden
| | - Anita McAllister
- Karolinska Institutet, CLINTEC, Division of Speech-language pathology, Stockholm, Sweden; Karolinska University Hospital, Theme Women's Health and Allied Health Professionals, Medical Unit Speech and Language Pathology, Stockholm, Sweden
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Hajjari P, Oldmark MH, Fernell E, Jakobsson K, Vinsa I, Thorsson M, Monemi M, Stenlund L, Fasth A, Furuhjelm C, Johnels JÅ, Gillberg C, Johnson M. Paediatric Acute-onset Neuropsychiatric Syndrome ( PANS) and intravenous immunoglobulin (IVIG): comprehensive open-label trial in ten children. BMC Psychiatry 2022; 22:535. [PMID: 35933358 DOI: 10.1186/s12888-022-04181-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment with intravenous immunoglobulin (IVIG) in children with Paediatric Acute-onset Neuropsychiatric Syndrome (PANS) has for many years been used on clinical indications, but the research evidence for its efficacy is insufficient. METHODS Open-label prospective in-depth trial including ten children (median age 10.3 years) with PANS, who received IVIG treatment 2 g/kg monthly for three months. Primary outcomes were changes in symptom severity and impairment from baseline to first and second follow-up visits one month after first and one month after third treatment, using three investigator-rated scales: Paediatric Acute Neuropsychiatric Symptom (PANS) scale, Clinical Global Impression - Severity and Improvement (CGI-S and CGI-I) scales. Secondary outcomes reported here were changes in Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores, and side effects. RESULTS All ten children received three treatments at one-month intervals according to study plan. From baseline to second follow-up marked reductions were seen in mean total PANS scale scores (p = .005), and CGI-S scores (p = .004). CGI-I ratings showed much to very much global improvement (mean CGI-I 1.8). Nine children had clinical response defined as > 30% reduction in PANS Scale scores. Improvements were also noted for CY-BOCS scores (p = .005), and in school attendance. Three children suffered moderate to severe temporary side effects after the first treatment, and the remaining seven had mild to moderate side effects. Side effects were much less severe after second and third treatments. CONCLUSIONS Considerable and pervasive improvements in symptoms and clinical impairments were seen in these ten children after three monthly IVIG treatments. Moderate to severe transient side effects occurred in three cases. TRIAL REGISTRATION EudraCT no. 2019-004758-27, Clinicaltrials.gov no. NCT04609761, 05/10/2020.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Gromark C, Hesselmark E, Djupedal IG, Silverberg M, Horne A, Harris RA, Serlachius E, Mataix-Cols D. A Two-to-Five Year Follow-Up of a Pediatric Acute-Onset Neuropsychiatric Syndrome Cohort. Child Psychiatry Hum Dev 2022; 53:354-364. [PMID: 33559023 PMCID: PMC7870456 DOI: 10.1007/s10578-021-01135-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/28/2022]
Abstract
Little is known about the long-term prognosis of children with pediatric acute-onset neuropsychiatric syndrome (PANS). Out of the 46 eligible patients from the Karolinska PANS cohort, 34 consented to participate in a follow-up (median 3.3 years). Participants underwent a thorough clinical evaluation and were classified according to their clinical course. Resulting groups were compared on clinical characteristics and laboratory test results. We observed significant reductions in clinician-rated PANS symptom severity and improved general function. Two patients were classified as remitted, 20 as relapsing-remitting, and 12 as having a chronic-static/progressive course. The latter group had an earlier onset, greater impairment and received more pharmacological and psychological treatments. Although remission was rare, the majority of children with PANS were significantly improved over the follow-up period but a non-negligible minority of patients displayed a chronic-static/progressive course and required additional treatments. The proposed definitions of flare and clinical course may be useful in future clinical trials.
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Affiliation(s)
- Caroline Gromark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. .,Centre for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden. .,Centre for Psychiatry Research, Child and Adolescent Psychiatry Research Center, Gävlegatan 22, 113 30, Stockholm, Sweden.
| | - Eva Hesselmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,Centre for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Ida Gebel Djupedal
- Centre for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maria Silverberg
- Centre for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - AnnaCarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden ,Division of Pediatric Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Robert A. Harris
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,Centre for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,Centre for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Johnson M, Fernell E, Gillberg C, Fasth A, Dinkler L, Blennow K, Zetterberg H. No neurochemical evidence of neuronal injury or glial activation in children with Paediatric Acute-onset Neuropsychiatric Syndrome. An explorative pilot study. World J Biol Psychiatry 2021; 22:800-804. [PMID: 33792486 DOI: 10.1080/15622975.2021.1907716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: Paediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterised by an acute onset of obsessive compulsive disorder, combined with at least two other neuropsychiatric symptoms with acute onset. Diagnostic criteria also require that no specific medical aetiology is identified. Although there are no verified aetiological biomarkers, PANS is assumed to be a neuroinflammatory disorder with a possible autoimmune aetiology. Neurochemical markers such as neurofilament light (NfL, a neuronal injury marker) and glial fibrillary acidic protein (GFAP, an astrocytic activation marker) have not been published for this patient group.Method: Blood samples from 17 children meeting diagnostic criteria for PANS, after assessment at a child neuropsychiatry clinic were analysed for serum concentrations of NfL and GFAP. Ten age-matched children without any neurological or psychiatric disorder served as a comparison group.Results: No difference was found in mean NfL and mean GFAP serum concentrations between children with PANS and controls.Conclusion: Neuronal injury and astrocyte activation do not seem to be a major event in PANS. The study group was small, and even if findings may be reassuring for parents and patients, they should be interpreted with caution and verified in larger cohorts and possibly with other markers in both serum and CSF.
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Affiliation(s)
- Mats Johnson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Child Neuropsychiatry Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Fernell
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Child Neuropsychiatry Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Child Neuropsychiatry Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Lisa Dinkler
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
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23
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De Visscher C, Hesselmark E, Rautio D, Djupedal IG, Silverberg M, Nordström SI, Serlachius E, Mataix-Cols D. Measuring clinical outcomes in children with pediatric acute-onset neuropsychiatric syndrome: data from a 2-5 year follow-up study. BMC Psychiatry 2021; 21:484. [PMID: 34607588 PMCID: PMC8488538 DOI: 10.1186/s12888-021-03450-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/26/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is unclear how to best measure the complex symptom presentation of pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS Well-characterized participants of a 2-5 year follow-up study (n = 34; 56% male) underwent clinical evaluations and completed scales assessing global symptom severity, functional impairment and specific psychiatric symptoms. We explored inter-correlations between the measures and used intraclass correlation coefficients to evaluate the agreement between clinician-, parent- and child ratings of the same constructs. RESULTS Ratings on symptom-specific measures varied largely between participants. Agreement between informants was excellent on functional scales, fair-to-moderate on global severity scales and mixed on symptom-specific scales. Clinician-rated global and functional measures had stronger inter-correlations with parent- and child-rated functional measures than with symptom-specific measures. CONCLUSIONS General instruments assessing global severity and functioning are well suited for the assessment and follow-up of PANS, but should be complemented by symptom-specific scales representative of core symptoms.
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Affiliation(s)
- Caroline De Visscher
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. .,Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden. .,Moment Psykologi, Drottninggatan 99, 113 60, Stockholm, Sweden.
| | - Eva Hesselmark
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
| | - Daniel Rautio
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
| | - Ida Gebel Djupedal
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
| | - Maria Silverberg
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
| | - Selma Idring Nordström
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
| | - Eva Serlachius
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
| | - David Mataix-Cols
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, CAP Research Center, Gävlegatan 22, SE-113 30, Stockholm, Sweden
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24
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Guido CA, Loffredo L, Zicari AM, Pavone P, Savasta S, Gagliano A, Brindisi G, Galardini G, Bertolini A, Spalice A. The Impact of the COVID-19 Epidemic During the Lockdown on Children With the Pediatric Acute-Onset Neuropsychiatric Syndrome (PANDAS/ PANS): The Importance of Environmental Factors on Clinical Conditions. Front Neurol 2021; 12:702356. [PMID: 34456853 PMCID: PMC8385147 DOI: 10.3389/fneur.2021.702356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: In March 2020, SARS-CoV-2 declared a pandemic by the World Health Organization. Restrictive isolation measures have also brought psychological distress to the pediatric population. Building on the syndrome's characteristics, the present study explored the impact of lockdown on the clinical course of young people with PANDAS/PANS. The initial hypothesis considered both the reduced exposure to viral agents and the strategies of the parents and other containment actions as protective factors against the worsening of symptoms. Methods: One hundred and eight children, adolescents, and young adults were recruited according to the multicenter PANDAS/PANS research program. Parents participated in a web-based survey. Results: contrary to our hypothesis, the study results show an increase in symptoms during the block in 71% of the sample. Psychometric analyzes allowed us to exclude a relationship between the main symptoms of PANDAS and the increase in symptoms or the presence of symptoms before the block and their increase over time. The increase in symptoms is best explained by the presence of sleep disturbances and emotional lability. The exacerbation also appears to be linked to the onset of new symptoms in children and adolescents with depressed moods and eating problems. Furthermore, irritability and oppositionality are significant predictors of acute exacerbation. Equally statistically significant is the factor linked to the effects of pandemic stress, such as the fear of contracting the virus. No significant associations for symptom reduction have been identified between parental strategies or other parent-initiated actions, but the study demonstrates that caregiver perceived efficacy on the strategies used can reduce the risk of exacerbation. Conclusion: This preliminary study highlights the importance of studying the causes of increased symptoms in children with PANDAS/PANS. Life events can exacerbate the clinical condition or generate new symptoms in young patients. In particular, environmental, family, and social changes in the course of clinical symptoms in PANDAS/PANS patients should be investigated. It highlights the importance of emotional and behavioral management, which can be improved by enhancing coping strategies in young people with PANDAS/PANS and their caregivers through a combination treatment in which CBT and PMT are included, in line with guidelines. Limits: An experimental proxy-report questionnaire not yet standardized and validated on the PANS/PANDAS pediatric clinical sample was used for the exploratory study. There is also a small sample size (N = 108) and the absence of a control group (pre-lockdown or children without PANDAS/PANS). It would be interesting to evaluate the exact long-term dimensions to see the course of symptoms after covid and conduct a new study focusing on the impact of stressful events on the clinical course of the syndrome.
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Affiliation(s)
- Cristiana Alessia Guido
- Department of Pediatrics, Child Neurology Division, Sapienza University of Rome, Rome, Italy.,Department of Developmental and Social Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Loffredo
- Department of Clinical, Internal, Anaesthetic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Piero Pavone
- Department of Clinical and Experimental Sciences Medicine, Division of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Salvatore Savasta
- Division of Pediatrics - Azienda Socio Sanitaria Territoriale (ASST) Crema, Crema, Italy
| | - Antonella Gagliano
- Child Neuropsychiatry Operating Unit, University of Cagliari, Cagliari, Italy
| | - Giulia Brindisi
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Giuliana Galardini
- Italian Association PANDAS Organizzazione di Volontariato Italia ODV, Firenze, Italy
| | - Antonella Bertolini
- Italian Association PANDAS Organizzazione di Volontariato Italia ODV, Firenze, Italy
| | - Alberto Spalice
- Department of Pediatrics, Child Neurology Division, Sapienza University of Rome, Rome, Italy
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25
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Melamed I, Kobayashi RH, O'Connor M, Kobayashi AL, Schechterman A, Heffron M, Canterberry S, Miranda H, Rashid N. Evaluation of Intravenous Immunoglobulin in Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2021; 31:118-128. [PMID: 33601937 PMCID: PMC7984935 DOI: 10.1089/cap.2020.0100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a clinical diagnosis in children who have an acute manifestation of varied neuropsychiatric symptoms, including obsessive compulsive disorder, eating disorders, tics, anxiety, irritability, and problems with attention/concentration. PANS may develop as a result of a postinfectious syndrome and may represent a new form of postinfectious autoimmunity. To test the hypothesis that multiple, consecutive infusions of intravenous immunoglobulin (IVIG) for PANS can be efficacious, a multisite, open-label study was designed. Methods: The primary endpoint was evaluation of the efficacy of IVIG [Octagam 5%] in PANS over a period of 6 months (six infusions) based on mean changes in psychological evaluation scores using 6 different assessments, including the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Clinical Global Impression of Severity, and the Parent-Rated Pediatric Acute Neuropsychiatric Symptom Scale (PANS Scale). Results: The final cohort consisted of 21 subjects (7 per site) with moderate to severe PANS. The mean age was 10.86 years (range: 4-16 years). Results demonstrated statistically significant reductions in symptoms from baseline to end of treatment in all six assessments measured. CY-BOCS results demonstrated statistically significant reductions in obsessive compulsive symptoms (p < 0.0001), resulting in >50% improvement sustained for at least 8 weeks after the final infusion and up to 46 weeks in a subset of subjects. Conclusions: In PANS, which may be associated with an underlying immune dysregulation, sequential infusions of IVIG [Octagam 5%] successfully ameliorated psychological symptoms and dysfunction, with sustained benefits for at least 8 weeks, and up to 46 weeks in a subset of subjects. In addition, baseline immune and autoimmune profiles demonstrated significant elevations in a majority of subjects, which requires further evaluation, characterization, and study to clarify the potential immune dysfunction by which PANS manifests and progresses.
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Affiliation(s)
| | - Roger H. Kobayashi
- Pediatric Immunology & Allergy, University of California, Los Angeles School of Medicine, Los Angeles, California, USA
| | - Maeve O'Connor
- Allergy, Asthma & Immunology Relief, Charlotte, North Carolina, USA
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26
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Harris EC, Conelea CA, Shyne MT, Bernstein GA. Predictors and Prospective Course of PANS: A Pilot Study Using Electronic Platforms for Data Collection. J Child Adolesc Psychopharmacol 2021; 31:102-108. [PMID: 33395354 PMCID: PMC8670571 DOI: 10.1089/cap.2020.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Little is known about the longitudinal course of pediatric acute-onset neuropsychiatric syndrome (PANS) because existing literature is primarily cross-sectional. To begin to address this gap, two digital platforms were used to prospectively monitor neuropsychiatric symptoms in children with PANS. The aim was to identify baseline clinical characteristics that would predict the course of neuropsychiatric symptoms over 12 weeks. We compared relative compliance between two electronic data acquisition platforms and evaluated agreement between parent-child ratings of symptoms. Methods: For 12 weeks, 20 children with PANS and their parents completed weekly rating scales of neuropsychiatric symptoms on Research Electronic Data Capture (REDCap) and concurrently parents completed tri-weekly ratings on My Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Chart, a symptom monitoring website. Longitudinal data were analyzed by using regression analyses. Results: Greater duration of time between onset of PANS and study enrollment was associated with worsening of parent-rated neuropsychiatric symptoms over 12 weeks (p = 0.05). Higher scores on parents' Caregiver Burden Inventory at baseline predicted that children would report more severe symptoms over the 12-week period (p = 0.01). Compliance rates for parents were 86.3% for the weekly REDCap PANS Symptoms Rating Scale compared with 53.8% for the tri-weekly My PANDAS Chart ratings. There was moderate agreement between children and parents on the PANS Symptom Rating Scale (r = 0.55, p < 0.0001). Conclusion: Our study highlights the utility of electronic methods for tracking longitudinal symptoms in children with PANS and suggests that particular baseline characteristics (e.g., delay in identification and treatment of PANS, greater caregiver burden) may be indicative of a differential trajectory of PANS course, with more severe symptoms over the short term. clinicaltrials.gov NCT04382716.
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Affiliation(s)
- Elizabeth C. Harris
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christine A. Conelea
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael T. Shyne
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gail A. Bernstein
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA.,Address correspondence to: Gail A. Bernstein, MD, Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, F282/2A West, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
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27
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Xu J, Liu RJ, Fahey S, Frick L, Leckman J, Vaccarino F, Duman RS, Williams K, Swedo S, Pittenger C. Antibodies From Children With PANDAS Bind Specifically to Striatal Cholinergic Interneurons and Alter Their Activity. Am J Psychiatry 2021; 178:48-64. [PMID: 32539528 PMCID: PMC8573771 DOI: 10.1176/appi.ajp.2020.19070698] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pediatric obsessive-compulsive disorder (OCD) sometimes appears rapidly, even overnight, often after an infection. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS, describes such a situation after infection with Streptococcus pyogenes. PANDAS may result from induced autoimmunity against brain antigens, although this remains unproven. Pilot work suggests that IgG antibodies from children with PANDAS bind to cholinergic interneurons (CINs) in the striatum. CIN deficiency has been independently associated with tics in humans and with repetitive behavioral pathology in mice, making it a plausible locus of pathology. The authors sought to replicate and extend earlier work and to investigate the cellular effects of PANDAS antibodies on cholinergic interneurons. METHODS Binding of IgG to specific neurons in human and mouse brain slices was evaluated ex vivo after incubation with serum from 27 children with rigorously characterized PANDAS, both at baseline and after intravenous immunoglobulin (IVIG) treatment, and 23 matched control subjects. Binding was correlated with symptom measures. Neural activity after serum incubation was assessed in mouse slices using molecular markers and electrophysiological recording. RESULTS IgG from children with PANDAS bound to CINs, but not to several other neuron types, more than IgG from control subjects, in three independent cohorts of patients. Post-IVIG serum had reduced IgG binding to CINs, and this reduction correlated with symptom improvement. Baseline PANDAS sera decreased activity of striatal CINs, but not of parvalbumin-expressing GABAergic interneurons, and altered their electrophysiological responses, in acute mouse brain slices. Post-IVIG PANDAS sera and IgG-depleted baseline sera did not alter the activity of striatal CINs. CONCLUSIONS These findings provide strong evidence for striatal CINs as a critical cellular target that may contribute to pathophysiology in children with rapid-onset OCD symptoms, and perhaps in other conditions.
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Affiliation(s)
- Jian Xu
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Rong-Jian Liu
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Shaylyn Fahey
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Luciana Frick
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519,Current address: Hunter James Kelly Research Institute,
University at Buffalo
| | - James Leckman
- Child Study Center, Yale University School of
Medicine,Department of Pediatrics, Yale University School of
Medicine
| | - Flora Vaccarino
- Child Study Center, Yale University School of
Medicine,Department of Neuroscience, Yale University School of
Medicine
| | - Ronald S. Duman
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Kyle Williams
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519,Current address: Department of Psychiatry, Massachusetts
General Hospital and Harvard Medical School
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National
Institute of Mental Health,PANDAS Physicians Network
| | - Christopher Pittenger
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519,Child Study Center, Yale University School of
Medicine,Interdepartmental Neuroscience Program, Yale
University,Address correspondence to: Christopher Pittenger,
Yale University School of Medicine, 34 Park Street 333b, New Haven, CT 06519.
Phone: 203-974-7675.
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28
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Gagliano A, Puligheddu M, Ronzano N, Congiu P, Tanca MG, Cursio I, Carucci S, Sotgiu S, Grossi E, Zuddas A. Artificial Neural Networks Analysis of polysomnographic and clinical features in Pediatric Acute-Onset Neuropsychiatric Syndrome ( PANS): from sleep alteration to "Brain Fog". Nat Sci Sleep 2021; 13:1209-1224. [PMID: 34326674 PMCID: PMC8315772 DOI: 10.2147/nss.s300818] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/17/2021] [Indexed: 02/05/2023] Open
Abstract
STUDY OBJECTIVES PANS (pediatric acute onset neuropsychiatric syndrome) is thought to be the result of several mechanisms and multiple etiologies, ranging from endocrine/metabolic causes to postinfectious autoimmune and neuroinflammatory disorders. Sleep disorders represent one of the most frequent manifestations of PANS, involving around 80% of patients. The present study describes the clinical and polysomnographic features in a group of PANS children identifying the relationships between sleep disorders and other PANS symptoms. METHODS All participants underwent a clinical evaluation including comprehensive sleep history, polysomnography, cognitive assessment and blood chemistry examination. A data mining approach with fourth-generation artificial neural networks has been used in order to discover subtle trends and associations among variables. RESULTS Polysomnography showed abnormality in 17 out of 23 recruited subjects (73.9%). In particular, 8/17 children (47%) had ineffective sleep, 10/17 (58.8%) fragmented sleep, 8/17 (47.1%) periodic limb movement disorder (PLMD) and 11/17 (64.7%) REM-sleep without atonia (RSWA). Most subjects presented more than one sleep disturbances. Notably, among the 19/23 patients diagnosed with Tic/Tourette disorder, 8/19 (42.1%) show PLMD and 10/19 (52.6%) RSWA. Artificial neural network methodology and the auto-contractive map exploited the links among the full spectrum of variables revealing the simultaneous connections among them, facing the complexity of PANS phenotype. CONCLUSION Disordered sleep represents, for prevalence and impact on quality of life, a cardinal symptom in patients with PANS. Thus, considering the weight of sleep disturbances on diagnosis and prognosis of PANS, we could consider the possibility of including them among the major diagnostic criteria.
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Affiliation(s)
- Antonella Gagliano
- Child & Adolescent Neuropsychiatry Unit, “Azienda Ospedaliera Brotzu” Hospital Trust, Cagliari, Italy
| | - Monica Puligheddu
- Sleep Disorder Centre, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Correspondence: Monica Puligheddu Sleep Disorder Research Center, Department of Medical Science and Public Health, University of Cagliari, asse didattico E. SS 554 bivio Sestu, Monserrato, Cagliari, 09042, ItalyTel +0706754952 Email
| | - Nadia Ronzano
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Patrizia Congiu
- Sleep Disorder Centre, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Marcello Giuseppe Tanca
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Ida Cursio
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Sara Carucci
- Child & Adolescent Neuropsychiatry Unit, “Azienda Ospedaliera Brotzu” Hospital Trust, Cagliari, Italy
| | - Stefano Sotgiu
- Child Neuropsychiatry Unit, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, Sassari, Italy
| | - Enzo Grossi
- Autism Research Unit, Villa Santa Maria Foundation, Como, Italy
| | - Alessandro Zuddas
- Child & Adolescent Neuropsychiatry Unit, “Azienda Ospedaliera Brotzu” Hospital Trust, Cagliari, Italy
- Section of Neuroscience & Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
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29
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Loffredo L, Spalice A, Salvatori F, De Castro G, Guido CA, Zicari AM, Ciacci P, Battaglia S, Brindisi G, Ettorre E, Nocella C, Salvatori G, Duse M, Violi F, Carnevale R. Oxidative stress and gut-derived lipopolysaccharides in children affected by paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. BMC Pediatr 2020; 20:127. [PMID: 32188439 PMCID: PMC7079429 DOI: 10.1186/s12887-020-02026-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/11/2020] [Indexed: 12/15/2022] Open
Abstract
Background Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections syndrome (PANDAS) identifies patients with acute onset of obsessive-compulsive and tic disorders. The objective of this study was to evaluate serum NOX2 levels, as well as 8-iso-prostaglandin F2α (8-iso-PGF2α) and lipopolysaccharide (LPS) of PANDAS patients. Methods In this study we wanted to compare serum levels of soluble NOX2-dp (sNOX-2-dp), iso-PGF2α and LPS in 60 consecutive subjects, including 30 children affected by PANDAS and 30 controls (CT) matched for age and gender. Serum zonulin was used as intestinal permeability assay. Results Compared with CT, PANDAS children had increased serum levels of sNOX-2-dp, 8-iso-PGF2α and LPS. Bivariate analysis showed that serum sNOX2-dp was significantly correlated with LPS (Rs = 0.359; p = 0.005), zonulin (Rs = 0.444; p < 0.001) and 8-iso-PGF2α (Rs = 0.704; p < 0.001). Serum LPS significantly correlated with zonulin (Rs = 0.610; p < 0.001), and 8-iso-PGF2α (Rs = 0.591; p = 0.001). Finally, a multiple linear regression analysis showed that serum 8-iso-PGF2α and zonulin were the only independent variables associated with sNOX2-dp (R2 = 68%). Conclusion This study shows that children affected by PANDAS have high circulating levels of sNOX2-dp, isoprostanes and of LPS that could be involved in the process of neuroinflammation.
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Affiliation(s)
- Lorenzo Loffredo
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Alberto Spalice
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | | | - Giovanna De Castro
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | | | - Anna Maria Zicari
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | - Paolo Ciacci
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy
| | - Simona Battaglia
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy
| | - Giulia Brindisi
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | - Evaristo Ettorre
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy
| | - Cristina Nocella
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | | | - Marzia Duse
- Department of Pediatrics, Sapienza University of Rome, Rome, 00161, Italy
| | - Francesco Violi
- Department of Clinical, Internal, Anaesthetic and Cardiovascular Sciences, Sapienza University of Rome, I Clinica Medica, Viale del Policlinico 155, 00161, Rome, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
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30
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Baj J, Sitarz E, Forma A, Wróblewska K, Karakuła-Juchnowicz H. Alterations in the Nervous System and Gut Microbiota after β-Hemolytic Streptococcus Group A Infection-Characteristics and Diagnostic Criteria of PANDAS Recognition. Int J Mol Sci 2020; 21:E1476. [PMID: 32098238 PMCID: PMC7073132 DOI: 10.3390/ijms21041476] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
The objective of this paper is to review and summarize conclusions from the available literature regarding Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). The authors have independently reviewed articles from 1977 onwards, primarily focusing on the etiopathology, symptoms, differentiation between similar psychiatric conditions, immunological reactions, alterations in the nervous system and gut microbiota, genetics, and the available treatment for PANDAS. Recent research indicates that PANDAS patients show noticeable alterations within the structures of the central nervous system, including caudate, putamen, globus pallidus, and striatum, as well as bilateral and lentiform nuclei. Likewise, the presence of autoantibodies that interact with basal ganglia was observed in PANDAS patients. Several studies also suggest a relationship between the presence of obsessive-compulsive disorders like PANDAS and alterations to the gut microbiota. Further, genetic predispositions-including variations in the MBL gene and TNF-α-seem to be relevant regarding PANDAS syndrome. Even though the literature is still scarce, the authors have attempted to provide a thorough insight into the PANDAS syndrome, bearing in mind the diagnostic difficulties of this condition.
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Affiliation(s)
- Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-090 Lublin, Poland
| | - Elżbieta Sitarz
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (E.S.); (A.F.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (E.S.); (A.F.)
| | - Katarzyna Wróblewska
- North London Forensic Service, Chase Farm Hospital, 127 The Ridgeway, Enfield, Middlesex EN2 8JL, UK;
| | - Hanna Karakuła-Juchnowicz
- Chair and 1st Department of Psychiatry, Psychotherapy and Early Intervention, Medical University of Lublin, Gluska Street 1, 20-439 Lublin, Poland;
- Department of Clinical Neuropsychiatry, Medical University of Lublin, Gluska Street 1, 20-439 Lublin, Poland
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Gromark C, Harris RA, Wickström R, Horne A, Silverberg-Mörse M, Serlachius E, Mataix-Cols D. Establishing a Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic: Baseline Clinical Features of the Pediatric Acute-Onset Neuropsychiatric Syndrome Cohort at Karolinska Institutet. J Child Adolesc Psychopharmacol 2019; 29:625-633. [PMID: 31170007 PMCID: PMC6786340 DOI: 10.1089/cap.2018.0127] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a descriptive clinical entity defined by the abrupt onset of psychiatric and somatic symptoms leading to significant loss of function. Data on well-characterized PANS patients are limited, biomarkers have yet to be identified, and a solid evidence base to guide treatment is lacking. In this study, we present our experience of a systematic evaluation of the first 45 patients included in a Swedish cohort. Methods: During the period 2014-2018, our clinic received 100 referrals regarding suspected PANS. All patients underwent a standardized psychiatric/medical evaluation by a child/adolescent psychiatrist and a clinical psychologist or a nurse. Those with severe symptoms were also assessed by a pediatric neurologist and a pediatric rheumatologist. Laboratory tests were obtained at different time points in an attempt to capture an active disease state. Results: Of the 100 referrals, 45 met strict PANS criteria and consented to participate in a long-term follow-up study. The median age at intake was 7.2 years (range 3.0-13.1) and 56% were male. Ninety-three percent fulfilled both criteria for acute/atypical onset of PANS symptoms and having had an infection in relation to onset. Sixteen percent had an onset of an autoimmune or inflammatory disorder in temporal relation to the onset of PANS-related symptoms. The most common onset symptoms were obsessive-compulsive disorder (89%), anxiety (78%), and emotional lability (71%). Twenty-four percent had a preexisting autoimmune disease (AD) and 18% a preexisting psychiatric/neuropsychiatric diagnosis. Sixty-four percent of biological relatives had at least one psychiatric disorder and 76% at least one AD or inflammatory disorder. Complement activation (37%), leukopenia (20%), positive antinuclear antibodies (17%), and elevated thyroid antibodies (11%) were the most common laboratory findings. Conclusions: In our PANS cohort, there was a strong indication of an association with AD. Further work is needed to establish whether any of the potential biomarkers identified will be clinically useful. Long-term follow-up of these patients using the Swedish national registers will enable a deeper understanding of the course of this patient group.
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Affiliation(s)
- Caroline Gromark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Robert A. Harris
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Neurology, Karolinska University Hospital, Solna, Sweden
| | - AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Rheumatology, Karolinska University Hospital, Solna, Sweden
| | - Maria Silverberg-Mörse
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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Guzel D, Yazici AB, Pek TM, Doganay S, Simsek ABS, Saglam K, Turan C, Yazici E. Atrial natriuretic peptide and posterior pituitary neurohormone changes in patients with acute schizophrenia. Neuropsychiatr Dis Treat 2018; 14:1855-1860. [PMID: 30038496 PMCID: PMC6052919 DOI: 10.2147/ndt.s169619] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Interactions between neuropeptides and psychiatric disorders have been investigated for many years. The aim of this study was to evaluate oxytocin (OXT), arginine-vasopressin (AVP), and atrial natriuretic peptide (ANP) and assess their interactions with each other, as well as investigate these changes with the manifestations of schizophrenia. PARTICIPANTS AND METHODS Thirty-four individuals having acute schizophrenia and 24 healthy individuals as the control group were included in the study. Positive and Negative Syndrome Scales, Global Assessment of Functionality score, and Clinical Global Impression (CGI) scores were measured. Serum hormone levels were analyzed using enzyme-linked immunosorbent assay and were compared with the clinical findings. RESULTS OXT levels were significantly lower and AVP levels were significantly higher in patients having acute schizophrenia than the control group. OXT was negatively correlated with Positive and Negative Syndrome Scales positive score and CGI score, while it was positively correlated with Global Assessment of Functionality score. AVP was negatively correlated with CGI score. ANP levels of the patients having schizophrenia were lower than the control group; however, there was no significant correlation with clinical findings. CONCLUSION The obtained data indicate that the AVP level was higher, but OXT and ANP levels were lower in the patients having acute schizophrenia. Specifically OXT is related with reduced disease severity and increased functionality.
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Affiliation(s)
- Derya Guzel
- Department of Physiology, School of Medicine, Sakarya University, Sakarya, Turkey
| | - Ahmet Bulent Yazici
- Department of Psychiatry, School of Medicine, Sakarya University, Sakarya, Turkey,
| | - Tugba Mutu Pek
- Department of Psychiatry, School of Medicine, Sakarya University, Sakarya, Turkey,
| | - Songul Doganay
- Department of Physiology, School of Medicine, Sakarya University, Sakarya, Turkey
| | | | - Kadir Saglam
- Department of Physiology, School of Medicine, Sakarya University, Sakarya, Turkey
| | - Caglar Turan
- Department of Psychiatry, School of Medicine, Sakarya University, Sakarya, Turkey,
| | - Esra Yazici
- Department of Psychiatry, School of Medicine, Sakarya University, Sakarya, Turkey,
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Marazziti D, Mucci F, Fontenelle LF. Immune system and obsessive-compulsive disorder. Psychoneuroendocrinology 2018; 93:39-44. [PMID: 29689421 DOI: 10.1016/j.psyneuen.2018.04.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recently, much attention has been devoted to the possible alterations of the immune system in obsessive-compulsive disorder (OCD). Therefore, the aim of this paper was to review the current literature on the relationships between OCD and immune system. METHODS A PubMed and Google Scholar search was performed with specific keywords. RESULTS In the childhood, much emphasis has been given to the relationship between group A Streptococcus (GAS) infection and the development of a group of clinical syndromes characterized by neuropsychiatric symptoms known as "pediatric autoimmune neuropsychiatric disorders associated with streptococcus" (PANDAS). However, more recently, PANDAS has been reconsidered and evolved towards pediatric acute-onset neuropsychiatric syndrome (PANS) and/or Childhood Acute Neuropsychiatric Syndrome (CANS) all characterized by the presence of typical of OCD symptoms and tics. In adult OCD patients, different immunological parameters have been described to differ from those of healthy control subjects, although a few numbers of studies were carred out and most of them performed in small samples. CONCLUSIONS Although the exact relationships between OCD and immune processes are still unclear, available literature supports their role in the pathophysiology of OCD, while providing a fascinating hint for possible immunotherapeutic treatments in OCD.
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Quagliariello A, Del Chierico F, Russo A, Reddel S, Conte G, Lopetuso LR, Ianiro G, Dallapiccola B, Cardona F, Gasbarrini A, Putignani L. Gut Microbiota Profiling and Gut-Brain Crosstalk in Children Affected by Pediatric Acute-Onset Neuropsychiatric Syndrome and Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections. Front Microbiol 2018; 9:675. [PMID: 29686658 PMCID: PMC5900790 DOI: 10.3389/fmicb.2018.00675] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/22/2018] [Indexed: 12/26/2022] Open
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections syndrome (PANDAS) are conditions that impair brain normal neurologic function, resulting in the sudden onset of tics, obsessive-compulsive disorder, and other behavioral symptoms. Recent studies have emphasized the crosstalk between gut and brain, highlighting how gut composition can influence behavior and brain functions. Thus, the present study investigates the relationship between PANS/PANDAS and gut microbiota ecology. The gut composition of a cohort of 30 patients with PANS/PANDAS was analyzed and compared to control subjects using 16S rRNA-based metagenomics. Data were analyzed for their α- and β-diversity; differences in bacterial distribution were detected by Wilcoxon and LEfSe tests, while metabolic profile was predicted via PICRUSt software. These analyses demonstrate the presence of an altered bacterial community structure in PANS/PANDAS patients with respect to controls. In particular, ecological analysis revealed the presence of two main clusters of subjects based on age range. Thus, to avoid age bias, data from patients and controls were split into two groups: 4-8 years old and >9 years old. The younger PANS/PANDAS group was characterized by a strong increase in Bacteroidetes; in particular, Bacteroides, Odoribacter, and Oscillospira were identified as potential microbial biomarkers of this composition type. Moreover, this group exhibited an increase of several pathways concerning the modulation of the antibody response to inflammation within the gut as well as a decrease in pathways involved in brain function (i.e., SCFA, D-alanine and tyrosine metabolism, and the dopamine pathway). The older group of patients displayed a less uniform bacterial profile, thus impairing the identification of distinct biomarkers. Finally, Pearson's analysis between bacteria and anti-streptolysin O titer reveled a negative correlation between genera belonging to Firmicutes phylum and anti-streptolysin O while a positive correlation was observed with Odoribacter. In conclusion, this study suggests that streptococcal infections alter gut bacterial communities leading to a pro-inflammatory status through the selection of specific bacterial strains associated with gut inflammation and immune response activation. These findings highlight the possibility of studying bacterial biomarkers associated with this disorder and might led to novel potential therapeutic strategies.
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Affiliation(s)
| | | | - Alessandra Russo
- Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sofia Reddel
- Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulia Conte
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Loris R Lopetuso
- Department of Internal Medicine, Gastroenterology and Hepatology, Catholic University of the Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Gianluca Ianiro
- Department of Internal Medicine, Gastroenterology and Hepatology, Catholic University of the Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Bruno Dallapiccola
- Scientific Directorate, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Cardona
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Gastroenterology and Hepatology, Catholic University of the Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Lorenza Putignani
- Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Unit of Parasitology Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Mohammad SS, Dale RC. Principles and approaches to the treatment of immune-mediated movement disorders. Eur J Paediatr Neurol 2018; 22:292-300. [PMID: 29289523 DOI: 10.1016/j.ejpn.2017.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 11/06/2017] [Accepted: 11/27/2017] [Indexed: 01/18/2023]
Abstract
Immune mediated movement disorders include movement disorders in the context of autoimmune encephalitis such as anti-NMDAR encephalitis, post-infectious autoimmune movement disorders such as Sydenham chorea, paraneoplastic autoimmune movement disorders such as opsoclonus myoclonus ataxia syndrome, and infection triggered conditions such as paediatric acute neuropsychiatric syndrome. This review focuses on the approach to treatment of immune mediated movement disorders, which requires an understanding of the immunopathogenesis, whether the disease is destructive or 'altering', and the natural history of disease. Factors that can influence outcome include the severity of disease, the delay before starting therapy, use of multimodal therapy and whether the course is monophasic or relapsing. Although the four main conditions listed above have different pathophysiological processes, there are general themes that broadly apply including: early diagnosis and treatment is better, minimise the severity of disease, escalate treatment if the patient is not responding to initial treatments, and minimise relapse.
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Affiliation(s)
- Shekeeb S Mohammad
- The Children's Hospital at Westmead Clinical School, Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Australia; TY Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, Sydney, Australia
| | - Russell C Dale
- The Children's Hospital at Westmead Clinical School, Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Australia; Brain and Mind Centre Westmead, University of Sydney, Australia.
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Brown KD, Farmer C, Freeman GM, Spartz EJ, Farhadian B, Thienemann M, Frankovich J. Effect of Early and Prophylactic Nonsteroidal Anti-Inflammatory Drugs on Flare Duration in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Observational Study of Patients Followed by an Academic Community-Based Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic. J Child Adolesc Psychopharmacol 2017; 27:619-628. [PMID: 28696786 PMCID: PMC5749580 DOI: 10.1089/cap.2016.0193] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the sudden onset of severe obsessive-compulsive symptoms and/or eating restriction along with at least two coinciding neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. We evaluated the impact of nonsteroidal anti-inflammatory drug (NSAID) treatment on flare duration in PANS/PANDAS. METHODS Patient inclusion criteria: Patients were included if they had at least one neuropsychiatric deterioration ("flare") that met strict PANS/PANDAS research criteria and for which flare duration could be assessed. Flare inclusion criteria: Any flare that started before October 15, 2016 was included and followed until the flare resolved or until the end of our data collection (November 1, 2016). Flare exclusion criteria: Flares were excluded if they were incompletely resolved, treated with aggressive immunomodulation, or treated with NSAIDs late (>30 days of flare onset). Ninety-five patients met study inclusion criteria and collectively experienced 390 flares that met flare criteria. Data were analyzed using multilevel linear models, adjusting for demographics, disease, and treatment covariates. RESULTS NSAID use was associated with a significantly shorter flare duration. Flares not treated with NSAIDs had a mean duration of approximately 12.2 weeks (95% CI: 9.3-15.1). Flares that occurred while the child was on NSAID maintenance therapy were approximately 4 weeks shorter than flares not managed with NSAIDs (95% CI: 1.85-6.24; p < 0.0001). Flares treated with NSAIDs within 30 days of flare onset were approximately 2.6 weeks shorter than flares not managed with NSAIDs (95% CI: 0.43-4.68; p = 0.02). Flares treated prophylactically and those treated early with NSAIDs did not differ in duration (p = 0.26). Among the flares that received NSAID treatment within the first 30 days, earlier intervention was modestly associated with shorter flare durations (i.e., for each day that NSAID treatment was delayed, flare duration increased by 0.18 weeks; 95% CI: 0.03-0.33; p = 0.02), though it was not statistically significant after controlling for covariates (p = 0.06). CONCLUSION NSAIDs given prophylactically or within 30 days of flare onset may shorten neuropsychiatric symptom duration in patients with new-onset and relapsing/remitting PANS and PANDAS. A randomized placebo-control clinical trial of NSAIDs in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla D. Brown
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - G. Mark Freeman
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Ellen J. Spartz
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Child & Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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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, PANS/PANDAS Consortium. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II-Use of Immunomodulatory Therapies. J Child Adolesc Psychopharmacol 2017; 27:574-593. [PMID: 36358107 PMCID: PMC9836706 DOI: 10.1089/cap.2016.0148] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Mahony T, Sidell D, Gans H, Cooperstock M, Brown K, Cheung JM, Farhadian B, Gustafson M, Thienemann M, Frankovich J. Palatal Petechiae in the Absence of Group A Streptococcus in Pediatric Patients with Acute-Onset Neuropsychiatric Deterioration: A Cohort Study. J Child Adolesc Psychopharmacol 2017; 27:660-666. [PMID: 28387528 DOI: 10.1089/cap.2016.0153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Palatal petechiae are 95% specific for streptococcal pharyngitis. Despite this, and despite prior research demonstrating that Group A Streptococcus (GAS) is a common antecedent to pediatric acute-onset neuropsychiatric syndrome (PANS) episodes, we anecdotally observed a low rate of documented GAS in patients with PANS and palatal petechiae. This retrospective chart review was conducted to formally report the rate of palatal petechiae and concurrent GAS in a cohort of patients with PANS and investigate other etiologic factors. METHODS The clinical notes of 112 patients seen at the Stanford PANS Clinic who met PANS research criteria were reviewed for mention of palatal petechiae. The medical records of patients who demonstrated palatal petechiae on physical examination were reviewed for signs of infection, a clinical history of trauma, and laboratory results that could indicate other causes of petechiae. RESULTS Twenty-three patients had documented palatal petechiae on physical examination (ages 5-16, 13/23 [57%] male). Fifteen patients had a rapid GAS test and GAS culture in the Stanford PANS clinic, all with negative results. Evidence of recent GAS infection was found in 8/23 (32%) patients (elevated GAS titers [n = 6] or documentation of a positive rapid GAS test at another facility [n = 2]), one of whom also had potential herpes simplex virus (HSV) infection. One patient had potential HSV infection and recent palatal trauma. No patients had thrombocytopenia. 14/23 (61%) of patients with palatal petechiae had no discernable cause of petechiae. 10/19 (53%) of patients had antihistone antibodies. CONCLUSIONS Despite the established relationship between palatal petechiae and GAS, no patient with palatal petechiae in our clinic tested positive for GAS and only 32% had evidence of recent GAS. Most did not have an identifiable cause for the palatal lesions. This finding suggests the potential for alternative causes of palatal petechiae or undetectable GAS in our patient population. The high prevalence of palatal petechiae without GAS infection suggests that the pathogenesis of PANS is multifactorial and may involve disruption or inflammation of the microvasculature. Additional research is needed to further elucidate these findings.
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Affiliation(s)
- Talia Mahony
- 1 Divisions of Pediatric, Department of Allergy, Immunology, and Rheumatology, Palo Alto, California.,2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California
| | - Douglas Sidell
- 3 Divisions of Pediatric, Department of Otolarynthology, Palo Alto, California
| | - Hayley Gans
- 4 Divisions of Pediatric, Department of Infectious Disease, Palo Alto, California
| | - Michael Cooperstock
- 5 Pediatric Infectious Disease, University of Missouri School of Medicine , Columbia Missouri
| | - Kayla Brown
- 1 Divisions of Pediatric, Department of Allergy, Immunology, and Rheumatology, Palo Alto, California.,2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California
| | - Joanne M Cheung
- 2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California
| | - Bahare Farhadian
- 2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California
| | - Melissa Gustafson
- 2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California
| | - Margo Thienemann
- 2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California.,6 Divisions of Pediatric, Department of Child & Adolescent Psychiatry, Stanford University School of Medicine , Palo Alto, California
| | - Jennifer Frankovich
- 1 Divisions of Pediatric, Department of Allergy, Immunology, and Rheumatology, Palo Alto, California.,2 Stanford PANS Clinic and Research Program at Lucile Packards Children's Hospital, Stanford School of Medicine , Palo Alto, California
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Spartz EJ, Freeman GM, Brown K, Farhadian B, Thienemann M, Frankovich J. Course of Neuropsychiatric Symptoms After Introduction and Removal of Nonsteroidal Anti-Inflammatory Drugs: A Pediatric Observational Study. J Child Adolesc Psychopharmacol 2017; 27:652-659. [PMID: 28696783 DOI: 10.1089/cap.2016.0179] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Accumulating evidence suggests that anti-inflammatory interventions can modulate neuropsychiatric symptoms. Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by an abrupt and dramatic onset of obsessive-compulsive (OC) symptoms and/or severely restrictive food intake and at least two coinciding, equally debilitating neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). Here, we describe the course of neuropsychiatric symptoms in patients diagnosed with PANS and PANDAS after introduction or removal of nonsteroidal anti-inflammatory drugs (NSAIDs). STUDY DESIGN We reviewed the electronic medical records (EMR) of 218 consecutive patients evaluated in our Stanford PANS Clinic for patients who met strict PANS or PANDAS research criteria and received NSAIDs for arthritis, pain, and/or psychiatric symptoms. We describe neuropsychiatric symptoms that were noted in the EMR before, during, and after NSAIDs were introduced or removed as the sole change in pharmacologic treatment. RESULTS Seventy-seven patients were included in the current study. Of the 52 trials in which NSAID addition was the sole change in treatment, 16 (31%) coincided with an improvement in patients' neuropsychiatric symptoms. Of the 57 trials in which removal of NSAID treatment was the sole change in treatment, 20 (35%) coincided with escalation in patients' neuropsychiatric symptoms. Thirty patients (39%) experienced side effects, mainly mild gastrointestinal symptoms, which self-resolved after removal of NSAID, reduction of dose, or change in NSAID. CONCLUSIONS Improvement in neuropsychiatric symptoms was evident in roughly one-third of NSAID treatment trials. A randomized clinical trial will be necessary to confirm whether NSAIDs are successful in reducing neuropsychiatric symptoms in youth with PANS.
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Affiliation(s)
- Ellen J Spartz
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
| | - G Mark Freeman
- 2 Pediatric Divisions of Psychiatry and Behavioral Sciences, Stanford University School of Medicine , Stanford, California
| | - Kayla Brown
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
| | - Bahare Farhadian
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
| | - Margo Thienemann
- 3 Pediatric Divisions of Child & Adolescent Psychiatry, Stanford University School of Medicine , Stanford, California
| | - Jennifer Frankovich
- 1 Pediatric Divisions of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine , Stanford, California
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Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part III-Treatment and Prevention of Infections. J Child Adolesc Psychopharmacol 2017; 27:594-606. [PMID: 36358106 PMCID: PMC9836684 DOI: 10.1089/cap.2016.0151] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) and its subset, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS), are emerging autoimmune encephalopathies of childhood. Management guidelines are needed. This article, from the PANS/PANDAS Consortium, presents a consensus management guideline for the infection components. Accompanying papers from the Consortium discuss psychiatric and immunomodulatory management. Methods: Literature was reviewed and integrated with the clinical experience of the authors to provide a set of practical guidelines. This article was submitted to all members of the PANS/PANDAS Consortium, and their additional comments were added. Results: The relationships between PANS and infections are reviewed. An approach to the retrospective diagnosis of group A streptococcal infection for an operational definition of PANDAS is proposed. An initial course of anti-streptococcal treatment is proposed for all newly diagnosed PANS cases. Chronic secondary antimicrobial prophylaxis is suggested for children with PANDAS who have severe neuropsychiatric symptoms or recurrent group A Streptococcus-associated exacerbations. Guidelines for children with non-streptococcal PANS include vigilance for streptococcal pharyngitis or dermatitis in the patient and close contacts. All patients with PANS or PANDAS should also be closely monitored for other intercurrent infections, including sinusitis and influenza. Intercurrent infections should be diagnosed and treated promptly according to current standard guidelines. A guideline for the assessment of infection at initial onset or during neuropsychiatric exacerbations is also presented. Standard immunizations and attention to vitamin D are encouraged. Data indicating limited utility of adenotonsillectomy and probiotics are presented. Conclusion: A working guideline for the management of infection issues in PANS and PANDAS, based on literature and expert opinion, is provided.
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Affiliation(s)
- Michael S Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Susan E Swedo
- Department of Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health (NIMH), Rockville, Maryland
| | - Mark S Pasternack
- Department of Pediatric Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
| | - Tanya K Murphy
- Director and Professor of Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida, St. Petersburg, Florida
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Brown K, Farmer C, Farhadian B, Hernandez J, Thienemann M, Frankovich J. Pediatric Acute-Onset Neuropsychiatric Syndrome Response to Oral Corticosteroid Bursts: An Observational Study of Patients in an Academic Community-Based PANS Clinic. J Child Adolesc Psychopharmacol 2017; 27:629-639. [PMID: 28714753 PMCID: PMC5749576 DOI: 10.1089/cap.2016.0139] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sudden-onset severe obsessive-compulsive symptoms and/or severely restrictive food intake with at least two coinciding, similarly debilitating neuropsychiatric symptoms define Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). When associated with Group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. Most patients have a relapsing-remitting course. Treatment outcome data for youth with PANS and PANDAS are limited. METHODS One hundred seventy-eight consecutive patients were seen in the Stanford PANS clinic between September 1, 2012 and January 15, 2016, of whom 98 met PANS or PANDAS criteria, had a single episode of PANS or relapsing/remitting course, and collectively experienced 403 flares. Eighty-five flares were treated with 102 total courses of oral corticosteroids of either short (4-5 days) or long (5 days-8 weeks) duration. Response to treatment was assessed within 14 days of initiating a short burst of corticosteroids and at the end of a long burst based on clinician documentation and patient questionnaires. Data were analyzed by using multilevel random-effects models. RESULTS Patients experienced shorter flares when treated with oral corticosteroids (6.4 ± 5.0 weeks vs. 11.4 ± 8.6 weeks) than when not treated (p < 0.001), even after controlling for presumed confounding variables, including age at flare, weeks since onset of PANS illness, sex, antibiotic treatment, prophylactic antibiotics, previous immunomodulatory treatment, maintenance anti-inflammatory therapy, psychiatric medications, and cognitive behavioral therapy (p < 0.01). When corticosteroids were given for the initial PANS episode, flares tended to be shorter (10.3 ± 5.7 weeks) than when not treated (16.5 ± 9.6 weeks) (p = 0.06). This difference was statistically significant after controlling for the relevant confounding variables listed earlier (p < 0.01). Earlier use of corticosteroids was associated with shorter flare durations (p < 0.001). Longer courses of corticosteroids were associated with a more enduring impact on the duration of neuropsychiatric symptom improvement (p = 0.014). CONCLUSION Corticosteroids may be a helpful treatment intervention in patients with new-onset and relapsing/remitting PANS and PANDAS, hastening symptom improvement or resolution. When corticosteroids are given earlier in a disease flare, symptoms improve more quickly and patients achieve clinical remission sooner. Longer courses of corticosteroids may result in more durable remissions. A double-blind placebo-controlled clinical trial of corticosteroids in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla Brown
- Division of Pediatrics, Department of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Joseph Hernandez
- Division of Pediatrics, Department of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Division of Pediatrics, Department of Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Chaouat B. The State of the Art of Hybrid RANS/LES Modeling for the Simulation of Turbulent Flows. Flow Turbul Combust 2017; 99:279-327. [PMID: 30069154 PMCID: PMC6044294 DOI: 10.1007/s10494-017-9828-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 06/13/2017] [Indexed: 06/08/2023]
Abstract
This review presents the state of the art of hybrid RANS/LES modeling for the simulation of turbulent flows. After recalling the modeling used in RANS and LES methodologies, we propose in a first step a theoretical formalism developed in the spectral space that allows to unify the RANS and LES methods from a physical standpoint. In a second step, we discuss the principle of the hybrid RANS/LES methods capable of representing a RANS-type behavior in the vicinity of a solid boundary and an LES-type behavior far away from the wall boundary. Then, we analyze the principal hybrid RANS/LES methods usually used to perform numerical simulation of turbulent flows encountered in engineering applications. In particular, we investigate the very large eddy simulation (VLES), the detached eddy simulation (DES), the partially integrated transport modeling (PITM) method, the partially averaged Navier-Stokes (PANS) method, and the scale adaptive simulation (SAS) from a physical point of view. Finally, we establish the connection between these methods and more precisely, the link between PITM and PANS as well as DES and PITM showing that these methods that have been built by different ways, practical or theoretical manners have common points of comparison. It is the opinion of the author to consider that the most appropriate method for a particular application will depend on the expectations of the engineer and the computational resources the user is prepared to expend on the problem.
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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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Gaughan T, Buckley A, Hommer R, Grant P, Williams K, Leckman JF, Swedo SE. Rapid Eye Movement Sleep Abnormalities in Children with Pediatric Acute-Onset Neuropsychiatric Syndrome ( PANS). J Clin Sleep Med 2016; 12:1027-32. [PMID: 27166296 DOI: 10.5664/jcsm.5942] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/07/2016] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVES Polysomnographic investigation of sleep architecture in children presenting with pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS Fifteen consecutive subjects meeting criteria for PANS (mean age = 7.2 y; range 3-10 y) underwent single-night full polysomnography (PSG) read by a pediatric neurologist. RESULTS Thirteen of 15 subjects (87%) had abnormalities detected with PSG. Twelve of 15 had evidence of rapid eye movement (REM) sleep motor disinhibition, as characterized by excessive movement, laughing, hand stereotypies, moaning, or the continuation of periodic limb movements during sleep (PLMS) into REM sleep. CONCLUSIONS This study shows various forms of REM sleep motor disinhibition present in a population of children with PANS.
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Affiliation(s)
- Thomas Gaughan
- Department of Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD
| | - Ashura Buckley
- Department of Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD
| | - Rebecca Hommer
- Department of Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD
| | - Paul Grant
- Department of Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD
| | - Kyle Williams
- Pediatric Neuropsychiatry and Immunology Program, Massachusetts General Hospital, Harvard University School of Medicine, Boston, MA
| | - James F Leckman
- Child Study Center, Yale University School of Medicine, New Haven, CT
| | - Susan E Swedo
- Department of Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD
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Bagian K, Hartung SQ. Is It PANS, CANS, or PANDAS? Neuropsychiatric Pediatric Disorders That Are Not Black and White--Implications for the School Nurse. NASN Sch Nurse 2015; 30:96-104. [PMID: 25816440 DOI: 10.1177/1942602x14554607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The terms pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), pediatric acute-onset neuropsychiatric syndrome (PANS), and childhood acute neuropsychiatric symptoms (CANS) have all been used to describe certain acute onset neuropsychiatric pediatric disorders. Additionally, controversy is ongoing concerning the diagnosis and etiology of the disorders. The school nurse, as a member of a multidisciplinary team, benefits from an awareness of these disorders, the resulting impact on school performance, and the recommended treatment. The school nurse assists the team through the development of an Individualized Healthcare Plan to help the student to achieve success in school.
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Affiliation(s)
- Kathy Bagian
- School Nurse, Northern High School, Dillsburg, PA
| | - Sheila Q Hartung
- Director, Graduate Community Health Program, Bloomsburg University, Bloomsburg, PA
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Tsirka T, Boukouvala S, Agianian B, Fakis G. Polymorphism p.Val231Ile alters substrate selectivity of drug-metabolizing arylamine N-acetyltransferase 2 (NAT2) isoenzyme of rhesus macaque and human. Gene 2013; 536:65-73. [PMID: 24333853 DOI: 10.1016/j.gene.2013.11.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/10/2013] [Accepted: 11/30/2013] [Indexed: 10/25/2022]
Abstract
Arylamine N-acetyltransferases (NATs) are polymorphic enzymes mediating the biotransformation of arylamine/arylhydrazine xenobiotics, including pharmaceuticals and environmental carcinogens. The NAT1 and NAT2 genes, and their many polymorphic variants, have been thoroughly studied in humans by pharmacogeneticists and cancer epidemiologists. However, little is known about the function of NAT homologues in other primate species, including disease models. Here, we perform a comparative functional investigation of the NAT2 homologues of the rhesus macaque and human. We further dissect the functional impact of a previously described rhesus NAT2 gene polymorphism, causing substitution of valine by isoleucine at amino acid position 231. Gene constructs of rhesus and human NAT2, bearing or lacking non-synonymous polymorphism c.691G>A (p.Val231Ile), were expressed in Escherichia coli for comparative enzymatic analysis against various NAT1- and NAT2-selective substrates. The results suggest that the p.Val231Ile polymorphism does not compromise the stability or overall enzymatic activity of NAT2. However, substitution of Val231 by the bulkier isoleucine appears to alter enzyme substrate selectivity by decreasing the affinity towards NAT2 substrates and increasing the affinity towards NAT1 substrates. The experimental observations are supported by in silico modelling localizing polymorphic residue 231 close to amino acid loop 125-129, which forms part of the substrate binding pocket wall and determines the substrate binding preferences of the NAT isoenzymes. The p.Val231Ile polymorphism is the first natural polymorphism demonstrated to affect NAT substrate selectivity via this particular mechanism. The study is also the first to thoroughly characterize the properties of a polymorphic NAT isoenzyme in a non-human primate model.
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Affiliation(s)
- Theodora Tsirka
- Democritus University of Thrace, Department of Molecular Biology and Genetics, Alexandroupolis, Greece
| | - Sotiria Boukouvala
- Democritus University of Thrace, Department of Molecular Biology and Genetics, Alexandroupolis, Greece
| | - Bogos Agianian
- Democritus University of Thrace, Department of Molecular Biology and Genetics, Alexandroupolis, Greece
| | - Giannoulis Fakis
- Democritus University of Thrace, Department of Molecular Biology and Genetics, Alexandroupolis, Greece.
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Macerollo A, Martino D. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept. Tremor Other Hyperkinet Mov (N Y) 2013; 3. [PMID: 24106651 PMCID: PMC3783973 DOI: 10.7916/d8zc81m1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/13/2013] [Indexed: 12/14/2022]
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcus infections (PANDAS) originated from the observational work of Swedo and collaborators, who formalized their definition in 1998 in a set of operational criteria. The application of these criteria, which focuses on tics and obsessive-compulsive symptoms as core symptoms, has encountered difficulties, eventually leading to a high rate of misdiagnosis. In particular, the core feature represented by the association between newly diagnosed infections and neuropsychiatric symptom relapses in youths with this diagnosis could not be demonstrated by longitudinal studies. Exploratory studies aiming to identify clinical or cognitive features that could discriminate PANDAS from other pediatric obsessive-compulsive and tic disorders present methodological limitations, and therefore are not conclusive. Other behavioral features, in addition to obsessive-compulsive symptoms and tics, have been included in pediatric acute-onset neuropsychiatric syndromes (PANS) and childhood acute neuropsychiatric syndromes (CANS), two new concepts recently proposed in order to define a much broader clinical spectrum encompassing etiologically diverse entities. Given the uncertainties on the clinical definition of PANDAS, it is not surprising that evidence in support of a post-infectious, immune-mediated pathophysiology is also insufficient. Anti-dopamine receptor antibodies might be relevant to both Sydenham's chorea (SC)-the prototypical post-streptococcal neuropsychiatric disorder-and some rare forms of encephalitis targeting the basal ganglia specifically, but studies exploring their association with children fulfilling Swedo's criteria for PANDAS have been inconclusive. Moreover, we lack evidence in favor of the efficacy of antibiotic prophylaxis or tonsillectomy in patients fulfilling Swedo's criteria for PANDAS, whereas a response to immune-mediated treatments like intravenous immunoglobulins has been documented by one study, but needs replication in larger trials. Overall, the available evidence does not convincingly support the concept that PANDAS are a well-defined, isolated clinical entity subdued by definite pathophysiological mechanisms; larger, prospective studies are necessary to reshape the nosography and disease mechanisms of post-streptococcal acute neuropsychiatric disorders other than SC. Research is also under way to shed further light on a possible relationship between streptococcal infections, other biological and psychosocial stressors, and the complex pathobiology of chronic tic disorders.
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Affiliation(s)
- Antonella Macerollo
- Sobell Department of Motor Neuroscience and Movement Disorders, National Hospital of Neurology and Neurosurgery, Institute of Neurology, University College London, London, United Kingdom
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