Documente Academic
Documente Profesional
Documente Cultură
DOI: 10.1097/INF.0000000000002295
Neuropsychiatric Syndrome
Downloaded from https://journals.lww.com/pidj by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+5UxwP5IFlBZklB5rd4O3hjii/vBK1W1Z4oEnWKsW7tnwdtdovgIMg== on 03/06/2019
D
Ellen R. Wald, MD
Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600
TE
Highland Avenue, Box 4108, Madison, Wisconsin 53792 U.S.A., Phone: 608-263-8558, Fax:
No reprints requested.
Presented in part at the Pediatric Academic Societies’ meeting, May 7, 2018, Toronto, Canada.
“Are the Goal Posts Moving? Current Controversies in the Diagnosis and Management of
The author acknowledges the helpful review of the manuscript by Dr. Dominic Co, Dr. Jennifer
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pediatric Autoimmune Neuropsychiatric Symptoms Associated with Streptococcal
Infection (PANDAS) as a clinical entity was advanced by investigators at the National Institute
of Mental Health with 5 elements constituting diagnostic criteria: (1) presence of obsessive
compulsive disorder (OCD) and/or tic disorder; (2) pre-pubertal onset of symptoms; (3) episodic
course characterized by acute, severe onset and dramatic symptom exacerbations; (4) temporal
D
relationship between group A beta-hemolytic streptococcal (GAS) infections and symptom onset
and exacerbations; and (5) association with neurologic abnormalities (e.g., choreiform
TE
movements, motor hyperactivity, tics).1 In the original description of 50 patients with PANDAS
approximately 40% of all presentations and exacerbations were able to be related to preceding or
concurrent GAS infections and each patient had at least one episode in which the relationship to
GAS was established.1 PANS is a diagnostic entity advanced more than a decade later to
EP
broaden the scope of these disorders and allow for other instigator events besides GAS. The
criteria for PANS include abrupt, dramatic overnight onset of OCD or severely restricted food
intake; concurrent abrupt onset of additional severe neuropsychiatric symptoms from at least 2 of
the following 7 categories: (1) anxiety; (2) emotional lability and/or depression; (3) irritability,
C
aggression, and/or severe oppositional behaviors; (4) developmental regression; (5) deterioration
sensory stimuli, hallucinations, dysgraphia, complex motor, and/or vocal tics; (7) somatic signs
and symptoms, including sleep disturbances, enuresis or urinary frequency and the requirement
A
that symptoms are not better explained by a known neurologic or medical disorder.2
several consensus statements have been published in recent years.3-6 The existence of PANDAS
has been controversial from the time of its first publication.7 For those of us familiar with the
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
sequelae of streptococcal disease and the concerns of community physicians faced with the care
of children with these neuropsychiatric symptoms, the controversy has proven to be a disservice
to both pediatricians and families. It has fostered a dismissive attitude toward important clinical
D
neuropsychiatric symptoms or the cause of exacerbations.
TE
sera of children diagnosed to have PANDAS.
Sydenham’s chorea
Before critiquing the current literature on PANDAS and PANS, it is essential to learn
lessons from the study of Sydenham’s chorea, which at this time is a bona fide and inarguable
EP
example of a pediatric autoimmune neuropsychiatric syndrome that is related to streptococcal
infection. It is the careful study and observation of children with Sydenham’s chorea that first
provided the stimulus for Dr. Susan Swedo to begin to think about the possibility of PANDAS.8,9
Critics of PANDAS7 mention that the concept of PANDAS was derived from observations that
C
“some” individuals with Sydenham’s chorea have associated psychiatric symptoms. However,
the “some” is actually 70% and in patients with recurrent chorea as a manifestation of acute
C
There are other characteristics about chorea that make it a unique manifestation of acute
A
rheumatic fever. Most important is the long latency period between the incident acute
pharyngitis and the onset of acute rheumatic fever – usually one to 3 months, but sometimes as
long as 9 months. Accompanying this observation is the acknowledgement that given the
possibility of this long latent period, the throat culture is likely to be negative and acute phase
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
reactants (ESR, CRP and WBC) as well as antistreptococcal antibody titers are unlikely to be
elevated.
Other lessons from acute rheumatic fever must be taken into account. First, many
pharyngeal infections caused by GAS that precede the development of acute rheumatic fever are
D
either subclinical or so mild that they do not result in medical attention.12,13 Secondly, not all
GAS cause acute rheumatic fever. In fact, only 16 of more than 240 emm types cause acute
TE
rheumatic fever and approximately 14 emm types are capable of causing acute
GAS).14,15 Although the likelihood of developing acute rheumatic fever after infection with a
rheumatogenic GAS that has not been treated ranges from 3-6%, the likelihood of acute
EP
rheumatic fever after infection with a non-rheumatogenic GAS, or acute glomerulonephritis after
an infection with a non-nephritogenic GAS, is zero.14 Investigators have pondered the low rate
of development of acute rheumatic fever after infection with rheumatogenic GAS.16 They have
recognized that there is definitely a genetic susceptibility that influences the likelihood of
C
developing acute rheumatic fever, so that while infection with a rheumatogenic strain of GAS is
“necessary” to cause acute rheumatic fever, it is not sufficient. These same features may be true
C
for those GAS that cause PANDAS, i.e., not all GAS may cause PANDAS, those that do may
require a genetic susceptibility, and many infections may not result in the development of this
A
non-suppurative complication. The latency period between the incident streptococcal infection
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Streptococcal serology
Regarding antistreptococcal serology, new data available from Hysmith and co-workers,
acquisitions in children occur without symptoms and that the antibody response to a variety of
D
antigens is quite variable. Although every instance of a new infection was accompanied by an
antibody response to at least one antigen (average 3.5 antigens), the response to antistreptolysin
TE
O (ASO) and anti-DNAase B occurred only in 67% of cases and the assays to demonstrate the
remaining antibody responses are not generally commercially available. Furthermore, ASO and
anti-DNAase B titers were shown to be elevated in some children who were carriers, almost
certainly reflecting the acute infection that preceded carriage. Accordingly, the interpretation of
EP
serologic findings is by no means straightforward.
Hopefully this discussion sheds light on a major concern, expressed repeatedly by critics
of PANDAS in a variety of previous publications,18-20 regarding the entity of PANDAS, that is,
C
the “strength of the GAS association with the onset and recurrence of tics, obsessive compulsive
Epidemiologic issues
The main approach taken by Gilbert et al in their most recent challenge to the existence
A
of PANDAS and its association with GAS is to discuss several epidemiologic studies that have
been reported regarding both PANDAS and PANS.7 They cite two prospective studies, 814
children (4 to 11 years of age) in one21 and 693 children (3 to 12 years) in the other,22 both of
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
PANDAS diagnosis. Given the previous discussion regarding rheumatogenic GAS and the
necessary genetic predisposition – this is not a compelling observation. Furthermore, all of the
children in both studies received treatment for their streptococcal infections. One can speculate,
with a great degree of assurance, that there may not have been any cases of acute rheumatic fever
or acute glomerulonephritis observed in either of these two cohorts. Clearly, that would not
D
invalidate the existence of these entities nor their association with GAS.
Next, they reviewed two prospective, longitudinal studies that used intensive clinical
TE
monitoring of cohorts of children known to have PANDAS (31 and 40 patients, respectively)
compared to a control group of children with OCD or Tourette’s syndrome without a PANDAS
history.23,24 They hypothesized that children meeting the criteria for PANDAS would have more
clinical exacerbations temporally linked to bona fide GAS infection than controls. One study
EP
demonstrated a higher rate24 of exacerbations while the other did not.25 Many exacerbations
were not associated with GAS, an observation made by Swedo in her original papers. Once
again, a failure to link exacerbations of PANDAS to new infections with GAS does not
The second component of the critique focuses on the strength of evidence that PANDAS
C
is an autoimmune process. It has been proposed that the pathophysiologic basis for PANDAS is
a form of molecular mimicry in which antibodies produced against streptococcal proteins are
A
also targeted to proteins in the basal ganglia. Gilbert outlines the requirements for confirmation
in a variety of reported studies and the failure to be able to consistently demonstrate changes in
the levels of antineuronal antibodies as patients improve and worsen. This concern should be
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
mitigated, in least in part, by a study demonstrating that a substantial component of the failure to
demonstrate consistent results were that “control” sera used in a variety of studies demonstrated
inconsistencies.25 Although this study is cited by the authors, these results were not highlighted.
Animal models may provide additional information to support or refute the diagnostic
D
entity of PANDAS. There are strong data in which animals hyperimmunized with GAS
demonstrate behavior consistent with PANDAS.26 When the serum is transferred to naïve
TE
rodents, similar behavioral and motor problems are observed, strengthening these
observations.27,28 However, Gilbert minimizes the importance of these results by noting that
human sera from patients with PANDAS did not induce behavioral changes in the rodent
model.29 Nonetheless, a study published in 2018 provides evidence that human sera from well-
EP
characterized patients with PANDAS binds to cholinergic interneurons in the striatum of study
mice.30 Furthermore, convalescent sera from patients after treatment with IVIG were no longer
capable of binding.
Gilbert et al7 strongly emphasize that it is essential that the treating physician be
regarding immunomodulation in severe cases. This admonition could be equally well applied to
A
the management of almost all autoimmune encephalidities for which “…there is no general
consensus in the literature regarding the best regimen or duration of treatment.”20 Furthermore,
while the guidelines are clearly not evidence-based, as there are few, if any, stringently
performed randomized controlled trials, the clinician must still care for these patients until such
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
time that high quality evidence is available. Many thoughtful and experienced clinicians from
multiple academic medical centers participated in these guidelines.3-6 While these factors do not
ensure that the guidelines are the best they could be, adopting a less critical attitude may help
D
1. When is it appropriate to look for the presence of GAS?
When a previously healthy pre-pubertal child presents with the very sudden and severe onset
TE
of OCD, food aversion, separation anxiety, urinary frequency or incontinence (almost certainly
accompanied by anxiety), a careful history and physical exam, as well as a mental health
evaluation should be performed. In addition, a diagnostic test (culture, rapid antigen detection or
nucleic acid amplification test31) to determine the presence of GAS is appropriate. The
EP
experience reported by Murphy and Pichichero32 is compelling in this regard. Albeit that this is
a single study in a single community, it demonstrates a very strong association between onset
and treatment of infection with GAS and the occurrence and suppression of symptoms.
Although the Committee on Infectious Diseases of the American Academy of Pediatrics does not
C
patients suspected to have PANDAS,15 their view is inconsistent with the approach
C
microbiologic test to assess for the presence of GAS is recommended, even in the absence of
A
symptoms or signs of pharyngitis, given the high frequency of acute infection with GAS which is
will effectively eliminate GAS and prevent acquisition of GAS if used prophylactically.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
What other work-up is appropriate in the child who presents with suspected PANDAS?
Routine evaluation with complete blood count, ESR, CRP and comprehensive metabolic
panel is probably excessive for most children presenting with mild to moderate OCD. Rather,
first line therapy for children who present with the acute onset of psychiatric symptoms should
include those treatments shown to be effective in high quality, randomized controlled trials –
D
cognitive behavioral therapy.33
Evaluation of children whose symptoms cannot be related to GAS and especially those who
TE
do not respond to usual therapy for the acute onset of psychiatric symptoms, should include
imaging of the central nervous system and evaluation of cerebrospinal fluid as well as a
the use of anti-inflammatory agents should be considered most optimally in the context of
EP
prospective studies so that there is systematic collection of data before and after treatments.
There is a desperate need for carefully controlled studies to inform our treatment of children with
In closing, it is important to appreciate the long-held skepticism that delayed the acceptance
C
of acute rheumatic fever as a sequelae of infection with GAS. It took more than 100 years. It
was not until 1984 that evidence of streptococcal infection was made a necessary correlate within
C
the Jones Criteria for the diagnosis of acute rheumatic fever to be considered.34,35 PANDAS and
PANS are real entities. Their prevalence is unknown and continued study is essential. However,
A
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
References
1. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders
Psychiatry 1998;155:264-71.
2. Swedo SLJ, Rose NR. From research subgroup to clinical syndrome: modifying the
D
PANDAS criteria to describe PANS (Pediatric Acute-onset Neuropsychiatric Syndrome).
TE
3. Thienemann M, Murphy T, Leckman J, et al. Clinical Management of Pediatric Acute-
Psychop 2017;27:574-93.
5. Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK, Consortium PP. Clinical
7. Gilbert DL, Mink JW, Singer HS. A Pediatric Neurology Perspective on Pediatric
10
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
8. Swedo SE, Rapoport JL, Cheslow DL, et al. High prevalence of obsessive-compulsive
9. Swedo SE, Leonard HL, Schapiro MB, et al. Sydenham's chorea: physical and
10. Swedo SE. Sydenham's chorea. A model for childhood autoimmune neuropsychiatric
D
disorders. JAMA 1994;272:1788-91.
11. Asbahr FR, Ramos RT, Negrao AB, Gentil V. Case series: increased vulnerability to
TE
obsessive-compulsive symptoms with repeated episodes of Sydenham chorea. J Am Acad
12. Wald ER, Dashefsky B, Feidt C, Chiponis D, Byers C. Acute rheumatic fever in western
14. Carapetis JR, Currie BJ, Mathews JD. Cumulative incidence of rheumatic fever in an
2000;124:239-44.
15. American Academy of Pediatrics Redbook. Group A Streptococcal Infections. 2018 Report
C
of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of
Pediatrics; 2018.
A
16. Bryant PA, Smyth GK, Gooding T, et al. Susceptibility to acute rheumatic fever based on
Immun 2014;82:753-61.
11
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
17. Hysmith ND, Kaplan EL, Cleary PP, Johnson DR, Penfound TA, Dale JB. Prospective
18. Singer HS, Gilbert DL, Wolf DS, Mink JW, Kurlan R. Moving from PANDAS to CANS. J
Pediatr 2012;160:725-31.
D
19. Singer HS. PANDAS: The Need to Use Definitive Diagnostic Criteria. Tremor Other
TE
20. Singer HS. Autoantibody-Associated Movement Disorders in Children: Proven and
21. Perrin EM, Murphy ML, Casey JR, et al. Does group A beta-hemolytic streptococcal
infection increase risk for behavioral and neuropsychiatric symptoms in children? Arch
EP
Pediatr Adolesc Med 2004;158:848-56.
22. Murphy TK, Snider LA, Mutch PJ, et al. Relationship of movements and behaviors to
2007;61:279-84.
C
23. Kurlan R, Johnson D, Kaplan EL, Tourette Syndrome Study G. Streptococcal infection and
24. Leckman JF, King RA, Gilbert DL, et al. Streptococcal upper respiratory tract infections
A
12
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
25. Singer HS, Mascaro-Blanco A, Alvarez K, et al. Neuronal antibody biomarkers for
Sydenham's chorea identify a new group of children with chronic recurrent episodic acute
D
immunological abnormalities after streptococcal exposure: a novel rat model of Sydenham
TE
87.
27. Lotan D, Benhar I, Alvarez K, et al. Behavioral and neural effects of intra-striatal infusion
2010;15:712-26.
29. Loiselle CR, Lee O, Moran TH, Singer HS. Striatal microinfusion of Tourette syndrome
C
and PANDAS sera: failure to induce behavioral changes. Mov Disord 2004;19:390-6.
2018;69:304-11.
A
31. Tanz RR, Zheng XT, Carter DM, Steele MC, Shulman ST. Caution Needed: Molecular
2018;7:e145-e7.
13
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
32. Murphy ML, Pichichero ME. Prospective identification and treatment of children with
33. Franklin ME, Sapyta J, Freeman JB, et al. Cognitive behavior therapy augmentation of
D
Study II (POTS II) randomized controlled trial. JAMA 2011;306:1224-32.
34. Garvey MA, Giedd J, Swedo SE. PANDAS: the search for environmental triggers of
TE
pediatric neuropsychiatric disorders. Lessons from rheumatic fever. J Child Neurol
1998;13:413-23.
35. Shulman ST, Kaplan EL, Bisno AL, et al. Jones criteria (revised) for guidance in the
14
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.