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Streptococcal infection and exacerbations of childhood tics and obsessive-compulsive symptoms: a prospective blinded
Roger Kurlan1, Dwight Johnson, Edward L Kaplan
1University of Rochester School of Medicine, Mt Hope Professional Building, 1351 Mt Hope Ave, Suite 100, Rochester, NY 14620, USA. roger_kurlan@urmc.rochester.edu
Insights
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) cases showed more exacerbations, but few were directly linked to Group A Streptococcus. PANDAS is not solely triggered by this infection, necessitating further research.
Area of Science:
- Neuroscience
- Pediatrics
- Infectious Diseases
Background:
- Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is a controversial clinical entity.
- Understanding the link between Group A beta-hemolytic streptococcus (GAS) infection and neuropsychiatric symptom exacerbations in children is crucial.
Purpose of the Study:
- To investigate if children meeting PANDAS criteria experience more clinical exacerbations temporally linked to GAS infection compared to controls.
- To determine the proportion of exacerbations in PANDAS cases that are demonstrably associated with GAS infection.
Main Methods:
- A prospective case-control study involving 40 matched pairs of children with PANDAS and controls.
- Intensive laboratory testing for GAS and clinical evaluations were conducted over a 2-year period, with additional testing during illnesses.
- Blinding of laboratory personnel and clinical raters to case/control status and test results ensured objectivity.
Main Results:
- Cases exhibited higher rates of clinical exacerbations and GAS infections than controls.
- Only 5 out of 64 exacerbations in cases were temporally associated (within 4 weeks) with a GAS infection.
- Over 75% of exacerbations in PANDAS cases lacked a clear temporal relationship to GAS infection.
Conclusions:
- Children meeting PANDAS criteria may represent a subgroup of tic and obsessive-compulsive disorder patients susceptible to GAS-triggered neuropsychiatric symptom exacerbations.
- GAS infection is not the sole or most frequent trigger for exacerbations in these patients.
- Further research is required to validate PANDAS as a distinct entity and identify specific symptom precipitants.
Objective:
If pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections is a unique clinical entity, we hypothesized that children meeting diagnostic criteria would have more clinical exacerbations temporally linked to bona fide group A beta-hemolytic streptococcus infection than matched control subjects (chronic tic and/or obsessive-compulsive disorder with no known temporal relationship to group A beta-hemolytic streptococcus infection).
Patients And Methods:
Subjects included 40 matched pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections case-control pairs who were prospectively evaluated with intensive laboratory testing for group A beta-hemolytic streptococcus and clinical measures for an average of 2 years. Additional testing occurred at the time of any clinical exacerbations or illness. Laboratory personnel were blinded to case or control status and clinical (exacerbation or not) condition. Clinical raters were blinded to the results of laboratory tests.
Results:
The cases had a higher clinical exacerbation rate and a higher bona fide group A beta-hemolytic streptococcus infection rate than the control group. Only 5 of 64 exacerbations were temporally associated (within 4 weeks) with a group A beta-hemolytic streptococcus infection, and all occurred in cases. The number (5.0) was significantly higher than the number that would be expected by chance alone (1.6). Yet, >/=75% of the clinical exacerbations in cases had no observable temporal relationship to group A beta-hemolytic streptococcus infection.
Conclusions:
Patients who fit published criteria for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections seem to represent a subgroup of those with chronic tic disorders and obsessive-compulsive disorder who may be vulnerable to group A beta-hemolytic streptococcus infection as a precipitant of neuropsychiatric symptom exacerbations. Group A beta-hemolytic streptococcus infection is not the only or even the most common antecedent event associated with exacerbations for these patients. Additional intensive studies are needed to determine whether there is clinical or scientific evidence to support separating out subgroups of tic disorder and/or obsessive-compulsive disorder patients based on specific symptom precipitants.
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