PANDAS

[Guest guest]

This is what we know as of 10/19/2002.

The acronym PANDAS stands for

Pediatric Autoimmune Neuropsychiatric Disorders Associated with

Streptococcal infections.

<<

http://www.medscape.com/viewarticle/445217

10/19/2002

American Academy of Child and Adolescent Psychiatry 49th Annual Meeting

|Conference Coverage of the American Association of Child and Adolescent

Psychiatry 49th Annual Meeting

PANDAS in Children -- Current Approaches

P. Barthel, MD

Introduction

Postinfectious autoimmune disorders in response to Streptococcus

infections were confirmed in the 1950s.[1] Rheumatic fever (RF) was the

prototype disorder and Sydenham chorea (SC) was identified, not only as

a criteria for the diagnosis of RF but also as a stand-alone

manifestation of the potential for a central nervous system autoimmune

response. SC can have a mix of both motor and psychiatric

manifestations, including hyperactivity, mood lability and, in severe

cases, psychosis. Behavioral symptoms often precede the motor

manifestations and can include obsessive-compulsive features. On

average, SC lasts about 6 months.[2]

Defining the PANDAS Subgroup

Swedo and colleagues[3] first proposed that some cases of

childhood-onset obsessive-compulsive disorder (OCD) might be, like SC, a

post-step disorder of immune character. They coined the acronym PANDAS

to identify the occurrence of pediatric autoimmune neuropsychiatric

disorders associated with streptococcal infections. This is a disorder

of prepubertal children with sudden and dramatic onset of OCD

post-streptococcal infection. Dr. Swedo,[4] from the Pediatric

Developmental and Neuropsychiatry branch of the National Institute of

Mental Health (NIMH), presented that these children have a remarkably

episodic course with remitting and relapsing OCD symptom severity. Her

criteria for a PANDAS presentation also require the presence of

associated neurologic problems. These are usually " choreiform "

movements, which, by definition, are not full-blown SC. In fact, these

are often subtle movements. They do not interfere with voluntary motor

control and may only be elicited with careful observation of the

extended hand/fingers. Such movements were present in 25 of 26 children

seen during an exacerbation of their OCD symptoms in the early studies

at NIMH.[5] The exacerbations must also have a temporal relationship to

repeated Group A beta-hemolytic Streptococcus (GABHS) infections.

Dr. Swedo reported that there was an initial sense by clinicians that a

larger spectrum of psychiatric disorders (eg, attention

deficit/hyperactivity disorder, autism, anorexia nervosa) might also be

placed under the PANDAS rubric. However, she feels strongly that this

subgroup classification should be reserved, at this time, for OCD and

tic disorders. The full Diagnostic and Statistical Manual of Mental

Disorders, 4th edition[6] criteria for these disorders must be met

before PANDAS should even be considered.

Current thinking, according to Dr. Swedo, does allow for " possible "

PANDAS to be considered if there is a child with a prepubertal onset

relapsing/remitting OCD and/or tic disorder. This is true only if the

neurologic problems and relationships to GABHS infections have not been

fully explored or documented. She feels that knowledge of the PANDAS

associations must encourage clinicians to search for the " missing "

criterion with each exacerbation. Thus, the pursuit of laboratory

confirmation of the GABHS infection should be undertaken.

Dr. Harry Hill,[7] Infectious Disease specialist and Streptococcus

researcher at the University of Utah School of Medicine, reported that

the current " rapid " streptococcal screens used in most clinics are

perfectly acceptable for proving the presence of the Streptococcus if

positive. However, if the rapid screen is negative, this is not a true

indication of the absence of infection. A full plate culture needs to be

done. Retrospective assessment of exposure to Streptococcus will require

the use of immune markers (eg, AntiStreptolysin O [ASO], Anti-Dnase-.

It should be recognized that the ASO titer is not elevated at the time

of acute infection. It is an antibody response peaking in 2-4 weeks. An

elevated level can last for 6-12 months before, barring reinfection or

other complications, it returns to baseline. Criteria for true

diagnostic titers require both acute and convalescent specimens.

Diagnostic levels (reported in Todd units) can vary among labs and are

age-dependent. Anti-Dnase-B (also known as Streptodornase) is less

discriminating (20% of the healthy population have elevated levels).

Since these titers rise more slowly and remain elevated longer, they may

be helpful in some cases. Franciosi stated that paired titers showing a

4-fold rise should be considered positive.[8] He also noted that

combined testing, using both tests along with the Antihyaluronidase

titer as a Streptococcus " panel, " is reported to be 90% confirmatory of

a Streptococcus infection.

Genetic Risks?

There does appear to be a genetic susceptibility to poststreptococcal

autoimmune disorders, including RF and SC. Previous research focused on

the D8/17 antibody. This monoclonal antibody identifies B-cell antigens

present in all patients with RF, where it has been studied

extensively.[9] Dr. , of the University of Florida, noted

that, unfortunately, it has been found to be rather nonspecific in

neuropsychiatric disorders. In addition, she and Dr. Hill[7] both

considered the reliability and validity of the assay to be suspect. The

lack of usefulness of this laboratory marker for any diagnostic purpose

in suspected childhood PANDAS was reinforced by Dr. McMahon.[10]

Therefore, currently, it seems to have no place in the assessment of

PANDAS in children.

Dr. McMahon, Child Psychiatrist and Geneticist at the University of

Utah, studied the broader area of general familial genetic risk. He

looked for the presence of OCD and tic disorders in families involved in

the current RF resurgence in his region. (Dr. Hill[7] reminded

clinicians that the incidence of RF was in significant decline through

the mid-1980s but is now more prevalent in some areas [eg, intermountain

region of the western United States] for reasons that are poorly

understood.) His goal was to see if Tourette disorder (TD) or OCD was

associated with the SC criteria for RF. In a pilot survey of 100

families, he found almost 4 times as many SC probands (22%) had

relatives with TD/tics or OCD than non-SC RF patients (6%). He feels

this supported an as yet unidentified " common genetic risk factor. " This

should prompt clinicians to be careful about the family history of

children who are suspected of PANDAS.

PANDAS -- Management and Treatment

The recent report by and Pichichero[12] is the first evidence

that it may be possible to identify children with potential PANDAS more

acutely. This report, from a vigilant pediatric practice, identified 12

children with new-onset PANDAS-like presentation over 3 years. All had

GABHS infection, sometimes mild in classical (ie,

tonsillitis/pharyngitis) presentation, with abrupt appearance of OCD

symptoms. (Intriguingly, in this study, there was also the new onset of

daytime urinary urgency/frequency in 7 of 12 patients.) If antibiotic

treatment was successful in eradicating the streptococcal infection, the

OCD symptoms also resolved. Recurrence of OCD symptoms, with recurrent

GABHS infection, was found in 6 of 12 children. Appropriate treatment

again relieved the OCD symptoms if the infection was managed. Given the

success of antibiotic treatment in the prevention of 90% of RF and 50%

of acute poststreptococcal glomerulonephritis, this study supports the

vigorous inquiry and treatment of GABHS infections as a potential

prevention effort of PANDAS as well.[7]

Treatment for the PANDAS subgroup of children with OCD is not different

from treatment for others with this diagnosis. Dr. recommended

the use of combined behavioral therapies and low doses of selective

serotonin reuptake inhibitors (SSRIs) with rapid taper to clinically

effective levels as reported in the literature.[9,11] Controversies

arise when treatment is less than ameliorating or if the exacerbations

are problematic.

Perlmutter and colleagues[13] have published the results of their

attempts at immunomodulatory therapy with more severe and treatment

resistant children with PANDAS. Part of the NIMH group studying these

disorders, they found that both intravenous pooled immunoglobulin (IVIG)

and plasma exchange (PE) were successful in reducing OCD and other

behavioral symptoms. Gains were maintained for up to 12 months. PE was

reported to produce more rapid onset of change (< 2 weeks) and had " more

striking " improvements in OCD.[5] Given the complications/risks of IVIG,

this is not recommended currently by Dr. Swedo as a treatment. She

agreed with the NIMH statement[14] that this is an experimental

intervention. Dr. Swedo did report that she feels that children with

more severe symptoms should be considered for therapeutic plasma

exchange if other interventions have failed and there is a clinical

exchange team available who has experience with young children.[4] She

indicated that families need to know this is an area of ongoing research

and that PE and other modalities for treatment are under continuing

study at NIMH.

An active question in that research is the effect of prophylactic

antibiotics (PAbx) in children with PANDAS. This is another difficult

area for clinicians. PAbx are routine for those with carditis resulting

from RF, and their success in prevention of further heart damage is a

clear indicator of the relationship between GABHS and RF. Early

studies[15] of PAbx in children with PANDAS have been complicated by

poor compliance and the dilemmas of placebo treatment. Since study

children will be at risk for GABHS infections through the study period,

ethically they require treatment. Dr. Swedo presented early indications

of clinical directions from unpublished data[4] but felt it was " too

early " to recommend this. Her strongest concern was how long to continue

antibiotics if they are started. This and other unanswered questions

will continue to guide the study of PANDAS.

Finally, the question of how much of " typical " OCD may have its genesis

in postinfectious etiology is a tantalizing one. Given the interest of

psychiatry and child psychiatry in finding clear etiologies for many

disorders, the possibilities of viral and bacterial contributions to

currently poorly understood disorders and their exacerbations make the

evolving PANDAS story a model for all clinicians to watch.

Clinical Correlation

An 8-year-old girl presents to her MD's office with sudden onset of

frequent hand washing with distress about " germs " ; she has a sore

throat. Mother is known to have struggled with OCD and dad has a tic

disorder. Mom is anxious about PANDAS!

The patient should be screened with a " rapid " strep test: if positive,

she should be treated with appropriate antibiotics; if negative, a plate

culture should be done. In either case, the family should be counseled

about appropriate behavioral approaches to the girl's

obsessive-compulsive symptoms. If mother has

a cognitive-behavioral therapist in place, a contact to that clinician

is appropriate. Appropriate follow-up of culture, treatment to

resolution of any infection, and tracking of OCD symptoms is indicated.

Four weeks later, the girl is more significantly involved with

obsessions and compulsions about germs. Contamination fears interfere

with comfort at school and home. Cognitive-behavioral therapy principles

have been initiated with some success. Mother has benefited from

fluvoxamine and feels her daughter will also.

Referral to a clinician skilled with the diagnosis and SSRI treatment of

OCD in children is appropriate, and formal cognitive-behavioral therapy

must be considered.

Six weeks later, she has multiple severe obsessive-compulsive anxieties

and evidence of " psychotic " beliefs. She is sleeping poorly and eating

is constricted due to her fears. After diagnosis of OCD, there was

initial positive response to the medication/therapy trial, but this

recently deteriorated.

The patient should be cultured again, and treated as appropriate. If

positive, a search for a Streptococcus " carrier " in the family should be

made. If negative, therapeutic plasma exchange might be considered.

Consultation to the PANDAS group at NIMH, or other local experts, about

this treatment and the potential usefulness of prophylactic antibiotics

should be sought.

References

1.Berrios X, del Campo E, Guzman B, Bisno AL. Discontinuing rheumatic

fever prophylaxis in selected adolescents and young adults. A

prospective study. Ann Intern Med. 1993;118:401-406.

2. T, Goodman W. Genetics of childhood disorders: XXXIV.

Autoimmune disorders, part 7: D8/17 reactivity as an immunological

marker of susceptibility to neuropsychiatric disorders. J Am Acad Child

Adolesc Psychiatry. 2002;41:98-100.

3.Swedo S, Leonard HL, Garvey M, et al. Pediatric autoimmune

neuropsychiatric disorders associated with streptococcal infection:

clinical descriptions of the first 50 cases. Am J Psychiatry.

1998;155:264-271.

4.Swedo S. Pediatric autoimmune neuropsychiatric disorders associated

with strep infections (PANDAS). Program and abstracts of the American

Academy of Child and

Adolescent Psychiatry 49th Annual Meeting; October 22-27, 2002; San

Francisco, California. Symposium 26.

5.Swedo SE. Pediatric autoimmune neuropsychiatric disorders associated

with streptococcal infections (PANDAS). Mol Psychiatry. 2002;7(suppl

2):S24-25.

6.American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders, fourth edition. Washington, DC: American Psychiatric

Association; 1994.

7.Hill H. Group A streptococcal infections and the pathogenesis of acute

rheumatic fever. Program and abstracts of the American Academy of Child

and Adolescent psychiatry 49th Annual Meeting; October 22-27, 2002; San

Francisco, California. Symposium 26.

8.Franciosi R. Laboratory Services Directory -- Vol. 2, Children's

Hospital of Wisconsin. Hudson, Oh: Lexi-Comp Inc; 1992.

9. T. Tics, compulsions and strep throat. Program and abstracts of

the American Academy of Child and Adolescent Psychiatry 49th Annual

Meeting; October 22-27, 2002; San Francisco, California. Institute 1.

10.McMahon W. Genetics of TD and RF: do they overlap? Program and

abstracts of the American Academy of Child and Adolescent Psychiatry

49th Annual Meeting; October 22-27, 2002; San Francisco, California.

Symposium 26.

11.Riddle M, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for

children and adolescents with obsessive-compulsive disorder; a

randomized, controlled, multicenter trial. J Am Acad Child Adolesc

Psychiatry. 2001;40:222-229.

12. M, Pichichero M. Prospective identification and treatment of

children with pediatric autoimmune neuropsychiatric disorder associated

with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med.

2002;156:356-361.

13.Perlmutter S, Leitman SF, Garvey MA, et al. Therapeutic plasma

exchange and intravenous immunoglobin for obsessive-compulsive disorder

and tic disorders in childhood. Lancet. 1999;354:1153-1158.

14.Plasma exchange and intravenous immunoglobin lack proven benefit and

carry risk for children with PANDAS, Tourette's syndrome, or OCD.

Available at

www.nimh.nih.gov/events/pandaalert.cfm. Accessed November 15, 2002.

15.Garvey MA, Perlmutter SJ, AJ, et al. A pilot study of

penicillin prophylaxis for neuropsychiatic exacerbations triggered by

streptococcal infections. Biol Psychiatry. 1999;45:1564-1571.

>>

[Guest guest]

Whoosh... a lot of this went right over my head:) But I was reminded

of a friend of mine who at about age5-6 began compulsively hand-

washing, about this same time, her brother (from what they've told

me) *became* epileptic. The mother claimed it was from a car

accident, but then later decided it was partially demonic possesion.

(who knows--) He had a terrible stutter--could barely talk and

began having grand-mal seizures. I don't know off hand if either of

them had Rhuematic fever/strep infections or anything like that. I

know that my friend " grew out " of the hand washing but then started

doing it again at about age 16.. She also had some real

emotional/mental --what have you--- problems. She stayed inside her

bedroom for like 12 months straight once, only coming out in the

middle of the night to eat. The tics/tourettes thing is what made me

think of her brother. We lived in a really " back-woods " sort of

place, so it wouldn't suprise me at all if he had tourettes and was

never diagnosed. I say this because he did seem to have many of the

symptoms (symptoms? characteristics?)of tourettes. So I'm wondering,

does this somewhat go along with what is posted below? (now my brain

hurts)

> This is what we know as of 10/19/2002.

>

> The acronym PANDAS stands for

> Pediatric Autoimmune Neuropsychiatric Disorders Associated with

> Streptococcal infections.

>

> <<

> http://www.medscape.com/viewarticle/445217

> 10/19/2002

> American Academy of Child and Adolescent Psychiatry 49th Annual

Meeting

> |Conference Coverage of the American Association of Child and

Adolescent

> Psychiatry 49th Annual Meeting

>

> PANDAS in Children -- Current Approaches

> P. Barthel, MD

>

> Introduction

>

> Postinfectious autoimmune disorders in response to Streptococcus

> infections were confirmed in the 1950s.[1] Rheumatic fever (RF) was

the

> prototype disorder and Sydenham chorea (SC) was identified, not

only as

> a criteria for the diagnosis of RF but also as a stand-alone

> manifestation of the potential for a central nervous system

autoimmune

> response. SC can have a mix of both motor and psychiatric

> manifestations, including hyperactivity, mood lability and, in

severe

> cases, psychosis. Behavioral symptoms often precede the motor

> manifestations and can include obsessive-compulsive features. On

> average, SC lasts about 6 months.[2]

>

> Defining the PANDAS Subgroup

>

> Swedo and colleagues[3] first proposed that some cases of

> childhood-onset obsessive-compulsive disorder (OCD) might be, like

SC, a

> post-step disorder of immune character. They coined the acronym

PANDAS

> to identify the occurrence of pediatric autoimmune neuropsychiatric

> disorders associated with streptococcal infections. This is a

disorder

> of prepubertal children with sudden and dramatic onset of OCD

> post-streptococcal infection. Dr. Swedo,[4] from the Pediatric

> Developmental and Neuropsychiatry branch of the National Institute

of

> Mental Health (NIMH), presented that these children have a

remarkably

> episodic course with remitting and relapsing OCD symptom severity.

Her

> criteria for a PANDAS presentation also require the presence of

> associated neurologic problems. These are usually " choreiform "

> movements, which, by definition, are not full-blown SC. In fact,

these

> are often subtle movements. They do not interfere with voluntary

motor

> control and may only be elicited with careful observation of the

> extended hand/fingers. Such movements were present in 25 of 26

children

> seen during an exacerbation of their OCD symptoms in the early

studies

> at NIMH.[5] The exacerbations must also have a temporal

relationship to

> repeated Group A beta-hemolytic Streptococcus (GABHS) infections.

>

> Dr. Swedo reported that there was an initial sense by clinicians

that a

> larger spectrum of psychiatric disorders (eg, attention

> deficit/hyperactivity disorder, autism, anorexia nervosa) might

also be

> placed under the PANDAS rubric. However, she feels strongly that

this

> subgroup classification should be reserved, at this time, for OCD

and

> tic disorders. The full Diagnostic and Statistical Manual of Mental

> Disorders, 4th edition[6] criteria for these disorders must be met

> before PANDAS should even be considered.

>

> Current thinking, according to Dr. Swedo, does allow for " possible "

> PANDAS to be considered if there is a child with a prepubertal onset

> relapsing/remitting OCD and/or tic disorder. This is true only if

the

> neurologic problems and relationships to GABHS infections have not

been

> fully explored or documented. She feels that knowledge of the PANDAS

> associations must encourage clinicians to search for the " missing "

> criterion with each exacerbation. Thus, the pursuit of laboratory

> confirmation of the GABHS infection should be undertaken.

>

> Dr. Harry Hill,[7] Infectious Disease specialist and Streptococcus

> researcher at the University of Utah School of Medicine, reported

that

> the current " rapid " streptococcal screens used in most clinics are

> perfectly acceptable for proving the presence of the Streptococcus

if

> positive. However, if the rapid screen is negative, this is not a

true

> indication of the absence of infection. A full plate culture needs

to be

> done. Retrospective assessment of exposure to Streptococcus will

require

> the use of immune markers (eg, AntiStreptolysin O [ASO], Anti-Dnase-

.

> It should be recognized that the ASO titer is not elevated at the

time

> of acute infection. It is an antibody response peaking in 2-4

weeks. An

> elevated level can last for 6-12 months before, barring reinfection

or

> other complications, it returns to baseline. Criteria for true

> diagnostic titers require both acute and convalescent specimens.

> Diagnostic levels (reported in Todd units) can vary among labs and

are

> age-dependent. Anti-Dnase-B (also known as Streptodornase) is less

> discriminating (20% of the healthy population have elevated levels).

> Since these titers rise more slowly and remain elevated longer,

they may

> be helpful in some cases. Franciosi stated that paired titers

showing a

> 4-fold rise should be considered positive.[8] He also noted that

> combined testing, using both tests along with the Antihyaluronidase

> titer as a Streptococcus " panel, " is reported to be 90%

confirmatory of

> a Streptococcus infection.

>

> Genetic Risks?

>

> There does appear to be a genetic susceptibility to

poststreptococcal

> autoimmune disorders, including RF and SC. Previous research

focused on

> the D8/17 antibody. This monoclonal antibody identifies B-cell

antigens

> present in all patients with RF, where it has been studied

> extensively.[9] Dr. , of the University of Florida,

noted

> that, unfortunately, it has been found to be rather nonspecific in

> neuropsychiatric disorders. In addition, she and Dr. Hill[7] both

> considered the reliability and validity of the assay to be suspect.

The

> lack of usefulness of this laboratory marker for any diagnostic

purpose

> in suspected childhood PANDAS was reinforced by Dr. McMahon.

[10]

> Therefore, currently, it seems to have no place in the assessment of

> PANDAS in children.

>

> Dr. McMahon, Child Psychiatrist and Geneticist at the University of

> Utah, studied the broader area of general familial genetic risk. He

> looked for the presence of OCD and tic disorders in families

involved in

> the current RF resurgence in his region. (Dr. Hill[7] reminded

> clinicians that the incidence of RF was in significant decline

through

> the mid-1980s but is now more prevalent in some areas [eg,

intermountain

> region of the western United States] for reasons that are poorly

> understood.) His goal was to see if Tourette disorder (TD) or OCD

was

> associated with the SC criteria for RF. In a pilot survey of 100

> families, he found almost 4 times as many SC probands (22%) had

> relatives with TD/tics or OCD than non-SC RF patients (6%). He feels

> this supported an as yet unidentified " common genetic risk factor. "

This

> should prompt clinicians to be careful about the family history of

> children who are suspected of PANDAS.

>

> PANDAS -- Management and Treatment

>

> The recent report by and Pichichero[12] is the first evidence

> that it may be possible to identify children with potential PANDAS

more

> acutely. This report, from a vigilant pediatric practice,

identified 12

> children with new-onset PANDAS-like presentation over 3 years. All

had

> GABHS infection, sometimes mild in classical (ie,

> tonsillitis/pharyngitis) presentation, with abrupt appearance of OCD

> symptoms. (Intriguingly, in this study, there was also the new

onset of

> daytime urinary urgency/frequency in 7 of 12 patients.) If

antibiotic

> treatment was successful in eradicating the streptococcal

infection, the

> OCD symptoms also resolved. Recurrence of OCD symptoms, with

recurrent

> GABHS infection, was found in 6 of 12 children. Appropriate

treatment

> again relieved the OCD symptoms if the infection was managed. Given

the

> success of antibiotic treatment in the prevention of 90% of RF and

50%

> of acute poststreptococcal glomerulonephritis, this study supports

the

> vigorous inquiry and treatment of GABHS infections as a potential

> prevention effort of PANDAS as well.[7]

>

> Treatment for the PANDAS subgroup of children with OCD is not

different

> from treatment for others with this diagnosis. Dr.

recommended

> the use of combined behavioral therapies and low doses of selective

> serotonin reuptake inhibitors (SSRIs) with rapid taper to clinically

> effective levels as reported in the literature.[9,11] Controversies

> arise when treatment is less than ameliorating or if the

exacerbations

> are problematic.

>

> Perlmutter and colleagues[13] have published the results of their

> attempts at immunomodulatory therapy with more severe and treatment

> resistant children with PANDAS. Part of the NIMH group studying

these

> disorders, they found that both intravenous pooled immunoglobulin

(IVIG)

> and plasma exchange (PE) were successful in reducing OCD and other

> behavioral symptoms. Gains were maintained for up to 12 months. PE

was

> reported to produce more rapid onset of change (< 2 weeks) and

had " more

> striking " improvements in OCD.[5] Given the complications/risks of

IVIG,

> this is not recommended currently by Dr. Swedo as a treatment. She

> agreed with the NIMH statement[14] that this is an experimental

> intervention. Dr. Swedo did report that she feels that children with

> more severe symptoms should be considered for therapeutic plasma

> exchange if other interventions have failed and there is a clinical

> exchange team available who has experience with young children.[4]

She

> indicated that families need to know this is an area of ongoing

research

> and that PE and other modalities for treatment are under continuing

> study at NIMH.

>

> An active question in that research is the effect of prophylactic

> antibiotics (PAbx) in children with PANDAS. This is another

difficult

> area for clinicians. PAbx are routine for those with carditis

resulting

> from RF, and their success in prevention of further heart damage is

a

> clear indicator of the relationship between GABHS and RF. Early

> studies[15] of PAbx in children with PANDAS have been complicated by

> poor compliance and the dilemmas of placebo treatment. Since study

> children will be at risk for GABHS infections through the study

period,

> ethically they require treatment. Dr. Swedo presented early

indications

> of clinical directions from unpublished data[4] but felt it was " too

> early " to recommend this. Her strongest concern was how long to

continue

> antibiotics if they are started. This and other unanswered questions

> will continue to guide the study of PANDAS.

>

> Finally, the question of how much of " typical " OCD may have its

genesis

> in postinfectious etiology is a tantalizing one. Given the interest

of

> psychiatry and child psychiatry in finding clear etiologies for many

> disorders, the possibilities of viral and bacterial contributions to

> currently poorly understood disorders and their exacerbations make

the

> evolving PANDAS story a model for all clinicians to watch.

>

> Clinical Correlation

>

> An 8-year-old girl presents to her MD's office with sudden onset of

> frequent hand washing with distress about " germs " ; she has a sore

> throat. Mother is known to have struggled with OCD and dad has a tic

> disorder. Mom is anxious about PANDAS!

>

> The patient should be screened with a " rapid " strep test: if

positive,

> she should be treated with appropriate antibiotics; if negative, a

plate

> culture should be done. In either case, the family should be

counseled

> about appropriate behavioral approaches to the girl's

> obsessive-compulsive symptoms. If mother has

> a cognitive-behavioral therapist in place, a contact to that

clinician

> is appropriate. Appropriate follow-up of culture, treatment to

> resolution of any infection, and tracking of OCD symptoms is

indicated.

>

> Four weeks later, the girl is more significantly involved with

> obsessions and compulsions about germs. Contamination fears

interfere

> with comfort at school and home. Cognitive-behavioral therapy

principles

> have been initiated with some success. Mother has benefited from

> fluvoxamine and feels her daughter will also.

>

> Referral to a clinician skilled with the diagnosis and SSRI

treatment of

> OCD in children is appropriate, and formal cognitive-behavioral

therapy

> must be considered.

>

> Six weeks later, she has multiple severe obsessive-compulsive

anxieties

> and evidence of " psychotic " beliefs. She is sleeping poorly and

eating

> is constricted due to her fears. After diagnosis of OCD, there was

> initial positive response to the medication/therapy trial, but this

> recently deteriorated.

>

> The patient should be cultured again, and treated as appropriate. If

> positive, a search for a Streptococcus " carrier " in the family

should be

> made. If negative, therapeutic plasma exchange might be considered.

> Consultation to the PANDAS group at NIMH, or other local experts,

about

> this treatment and the potential usefulness of prophylactic

antibiotics

> should be sought.

>

> References

>

> 1.Berrios X, del Campo E, Guzman B, Bisno AL. Discontinuing

rheumatic

> fever prophylaxis in selected adolescents and young adults. A

> prospective study. Ann Intern Med. 1993;118:401-406.

>

> 2. T, Goodman W. Genetics of childhood disorders: XXXIV.

> Autoimmune disorders, part 7: D8/17 reactivity as an immunological

> marker of susceptibility to neuropsychiatric disorders. J Am Acad

Child

> Adolesc Psychiatry. 2002;41:98-100.

>

> 3.Swedo S, Leonard HL, Garvey M, et al. Pediatric autoimmune

> neuropsychiatric disorders associated with streptococcal infection:

> clinical descriptions of the first 50 cases. Am J Psychiatry.

> 1998;155:264-271.

>

> 4.Swedo S. Pediatric autoimmune neuropsychiatric disorders

associated

> with strep infections (PANDAS). Program and abstracts of the

American

> Academy of Child and

> Adolescent Psychiatry 49th Annual Meeting; October 22-27, 2002; San

> Francisco, California. Symposium 26.

>

> 5.Swedo SE. Pediatric autoimmune neuropsychiatric disorders

associated

> with streptococcal infections (PANDAS). Mol Psychiatry. 2002;7(suppl

> 2):S24-25.

>

> 6.American Psychiatric Association. Diagnostic and Statistical

Manual of

> Mental Disorders, fourth edition. Washington, DC: American

Psychiatric

> Association; 1994.

>

> 7.Hill H. Group A streptococcal infections and the pathogenesis of

acute

> rheumatic fever. Program and abstracts of the American Academy of

Child

> and Adolescent psychiatry 49th Annual Meeting; October 22-27, 2002;

San

> Francisco, California. Symposium 26.

>

> 8.Franciosi R. Laboratory Services Directory -- Vol. 2, Children's

> Hospital of Wisconsin. Hudson, Oh: Lexi-Comp Inc; 1992.

>

> 9. T. Tics, compulsions and strep throat. Program and

abstracts of

> the American Academy of Child and Adolescent Psychiatry 49th Annual

> Meeting; October 22-27, 2002; San Francisco, California. Institute

1.

>

> 10.McMahon W. Genetics of TD and RF: do they overlap? Program and

> abstracts of the American Academy of Child and Adolescent Psychiatry

> 49th Annual Meeting; October 22-27, 2002; San Francisco, California.

> Symposium 26.

>

> 11.Riddle M, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for

> children and adolescents with obsessive-compulsive disorder; a

> randomized, controlled, multicenter trial. J Am Acad Child Adolesc

> Psychiatry. 2001;40:222-229.

>

> 12. M, Pichichero M. Prospective identification and treatment

of

> children with pediatric autoimmune neuropsychiatric disorder

associated

> with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc

Med.

> 2002;156:356-361.

>

> 13.Perlmutter S, Leitman SF, Garvey MA, et al. Therapeutic plasma

> exchange and intravenous immunoglobin for obsessive-compulsive

disorder

> and tic disorders in childhood. Lancet. 1999;354:1153-1158.

>

> 14.Plasma exchange and intravenous immunoglobin lack proven benefit

and

> carry risk for children with PANDAS, Tourette's syndrome, or OCD.

> Available at

> www.nimh.nih.gov/events/pandaalert.cfm. Accessed November 15, 2002.

>

> 15.Garvey MA, Perlmutter SJ, AJ, et al. A pilot study of

> penicillin prophylaxis for neuropsychiatic exacerbations triggered

by

> streptococcal infections. Biol Psychiatry. 1999;45:1564-1571.

>

> >>

[Guest guest]

The PANDAS profile is a test from Neuroscience Lab. My DAN ordered it. It tests for

.. Antibodies to the extra cellular products of Group A Streptococci which collectively are named Streptozyme

Streptolysin O (SO)

Streptokinase (SK)

Hyaluronidase (SH)

Deoxyribonuclease (DNase)

Nicotinamide Adenine Dinucleotidase (NADase)

2. Antibodies to streptococcal cell components

M5 peptide

M12 peptide

M19 peptide

3. Antibodies to B-cell autoantigen

D8/17

4. Anti-brain antibodies

Myelin basic protein

Ganglioside (Asialoganglioside GM1)

All of these were abnormal for my son, some of them 2-3x higher than the highest number in the "normal" range.

Kerrie

Thats discouraging. It was the ASO titer that was positive. There is another test ? Is that the DNASE ? We only got the ASO.>

Delicious ideas to please the pickiest eaters. Watch the video on AOL Living.

[Guest guest]

Thats discouraging. It was the ASO titer that was positive. There is

another test ? Is that the DNASE ? We only got the ASO.

>

>

> For us its been nothing but bad. We didn't do the titers you did,

we did a

> PANDAS profile and my son's numbers were a horror story!!! He's

had 4 monthly

> injections of Bicillin so far and we haven't seen any change in

symptoms. We

> are re-running the PANDAS profile this month to see if the numbers

are

> changing. With his behaviors/symptoms still horrible I doubt they

are

>

> I was so happy when we found out my son had PANDAS because it

explained his

> rapid decline after an incredible 6 months with fantastic gains. I

finally had

> an answer for something. But its not an answer that has an easy

solution.

> After doing a lot of research I found that some kids can take up

to 3 years to

> get better and there are some kids out there that never quite

recover from

> PANDAS

>

> kerrie

>

> In a message dated 2/22/2008 12:01:49 P.M. Eastern Standard Time,

> theshannster2@... writes:

>

> HI, my son came back pos+ for PANDAS. Christel, you were right.

Jake

> had the mystery rash and the OCD's + etc.

> Just got the call.

> Going on Pen VK

> Is this a Bad but good thing, can anyone chime in here???--- In

>

>

>

>

>

>

> **************Ideas to please picky eaters. Watch video on AOL

Living.

> (http://living.aol.com/video/how-to-please-your-picky-eater/rachel-

campos-duffy/

> 2050827?NCID=aolcmp00300000002598)

>

[Guest guest]

Why did the Doc choose inj. of bicillin over the Pen VK

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[Guest guest]

I don't know. That's what he said they normally start with and if we didn't see the numbers go down then we will switch to PenVK. That was from the DAN. His ped does the injections and has offered to switch us to either Zithromax or PenVK at anytime. The injections are horrible.

Can I ask your child's age/weight and how much Pen VK you are giving? My pediatrician really has no experience with PANDAS and is just doing what my DAN suggests. I want to make sure if we do end up switching that my son is getting a proper dose

thanks

Kerrie

Why did the Doc choose inj. of bicillin over the Pen VK

Delicious ideas to please the pickiest eaters. Watch the video on AOL Living.

[Guest guest]

Kerrie, my son is 4 1/2 and he weighs 47 lbs. His Penicillin VK dose

is 1.5 tsp 3x a day for 10 days, then 1 tsp 2x a day for 1 month. The

strength is 250mg/5ml. He is just starting it today, so I cant

really say much else at this time.Hope this helps...

>

>

> I don't know. That's what he said they normally start with and if

we didn't

> see the numbers go down then we will switch to PenVK. That was

from the DAN.

> His ped does the injections and has offered to switch us to either

Zithromax

> or PenVK at anytime. The injections are horrible.

>

> Can I ask your child's age/weight and how much Pen VK you are

giving? My

> pediatrician really has no experience with PANDAS and is just doing

what my DAN

> suggests. I want to make sure if we do end up switching that my

son is

> getting a proper dose

>

> thanks

> Kerrie

>

> In a message dated 2/23/2008 9:49:59 A.M. Eastern Standard Time,

> theshannster2@... writes:

>

> Why did the Doc choose inj. of bicillin over the Pen VK

>

>

>

>

>

>

> **************Ideas to please picky eaters. Watch video on AOL

Living.

> (http://living.aol.com/video/how-to-please-your-picky-eater/rachel-

campos-duffy/

> 2050827?NCID=aolcmp00300000002598)

>

[Guest guest]

Thanks so much. That helps alot. My son weighs 50 lbs so the dose would probably be the same. It will be nice to walk in with a suggestion for my pediatrician. She has been great and is very open minded about biomed. She even referred a few people to my DAN and one or two with GI issues to Dr. Krigsman after hearing me talk about things and seeing changes in my son.

kerrie

Kerrie, my son is 4 1/2 and he weighs 47 lbs. His Penicillin VK dose is 1.5 tsp 3x a day for 10 days, then 1 tsp 2x a day for 1 month. The strength is 250mg/5ml. He is just starting it today, so I cant really say much else at this time.Hope this helps...

Delicious ideas to please the pickiest eaters. Watch the video on AOL Living.

[Guest guest]

You are soooo blessed to have this ped!  Don't let her go!CherylThanks so much. That helps alot. My son weighs 50 lbs so the dose would probably be the same.  It will be nice to walk in with a suggestion for my pediatrician. She has been great and is very open minded about biomed. She even referred a few people to my DAN and one or two with GI issues to Dr. Krigsman after hearing me talk about things and seeing changes in my son. kerrie In a message dated 2/23/2008 6:06:14 P.M. Eastern Standard Time, theshannster2 writes:Kerrie, my son is 4 1/2 and he weighs 47 lbs. His Penicillin VK dose is 1.5 tsp 3x a day for 10 days, then 1 tsp 2x a day for 1 month. The strength is 250mg/5ml.  He is just starting it today, so I cant really say much else at this time.Hope this helps...  Delicious ideas to please the pickiest eaters. Watch the video on AOL Living.