Paediatric
Autoimmune Neuropsychiatric Disorder Associated with Streptococcus.
Have you noticed how different
your child has been acting ever since he had that sore throat? He seems
hyperactive, moody and keeps blinking his eyes. He also has become very
particular about the way he does certain things. His teachers say that
he's not paying attention in class and they're having trouble reading
his handwriting.
Your child may have developed what the medical community has named PANDAS.
Although rare, PANDAS stands for Paediatric Autoimmune Neuropsychiatric
Disorders Associated with Streptococcus. What does all that mean? Basically,
it means that when the body's defences are trying to attack the Streptococcal
bacteria causing the sore throat, there is some degree of mistaken identity
and it also attacks some parts of the brain.
The autoimmune attack is thought
to occur on closely related parts of the brain, causing a range of behavioural
and emotional problems. When first discovered PANDAS was linked to obsessive-compulsive
disorder, Tics and Tourettes syndrome. Mostly because these abnormal behaviours
are overt and easily recognised.
Tics can be uncontrollable movements, such as eye-blinking or shoulder-shrugging,
or automatic noises such as throat clearing, grunting or saying certain
words repeatedly. More recently PANDAS has been associated with a wider
range of related behaviours. Affected children can have any combination
of the following symptoms:
- Cognitive inflexibility,
difficult to reason with, as if stuck on an idea,
- Obsessive/repetitive/compulsive
argumentative behaviours,
- TICS (repetitive vocalisations
of body movements),
- Tourettes Syndrome,
- Attention deficits and oppositional/defiant
behaviours.
The bacteria associated with
this disorder are known as Group A Beta-Haemolytic Streptococcus (GABHS).
They are also the bacteria associated with rheumatic fever, a disease
characterised by heart and joint inflammation that can occur after an
untreated strep throat. A type of rheumatic fever with mostly neurological
symptoms is Sydenham's chorea (also known as St. Vitus Dance). Symptoms
of Sydenham chorea may occur several weeks to months after the infection
and may include poor or diminished muscle control and tone, poor coordination
and awkward movements of the face, body, arms and legs.
Children may also have
changes in their behaviours. Generally, after several weeks, all or
most of the symptoms go away and may return if the child develops another
Strep throat infection (detected or undetected). However, in a number
of cases recent outbreaks of rheumatic fever, signs of a recent sore
throat were absent or minimal. To prevent relapses, doctors will treat
patients with a history of rheumatic fever (including Sydenham chorea)
with a daily dose of antibiotics as a preventative measure against future
infections.
| Typically, a
child with undiagnosed PANDAS may be taken to the Psychologist and/or
Paediatrician for treatment of an onset or exacerbation of ADHD symptoms,
oppositional behaviours or OCD. Stimulant or anti-depressant medication
may be prescribed and/or a behavioural intervention or counselling initiated.
As the infection passes and the strep antibodies reduce, the symptoms
gradually subside and parents and clinicians believe that the intervention
was successful. However then there is another strep infection, the symptoms return
and the process is repeated. The problem is that the brain is being
continuously damaged by the repeated attacks by streptococcus antibodies;
and after each attack the recovery of damaged brain tissues may not
be as complete as we would hope. Eventually the child may develop a
chronic psychiatric disorder |
|
At the clinic, we check
for evidence of a recent strep infection by ordering a special blood
test that looks for Streptococcus antibodies (Serology for ASOT and AntiDNAseB).
Evidence of a recent streptococcal infection may or may not mean that
your child has PANDAS. Many children, up to 30 percent, will show evidence
by blood test of a recent streptococcal infection. So connecting symptoms
with a streptococcal infection will not necessarily mean that the infection
was the cause of the child's behaviour change. PANDAS will not develop
in every child with a strep infection.
Research is currently being
done at the NIMH to find out whether the select few are genetically
predisposed, or perhaps were exposed to a special strain of Strep. But
for now, until we can determine the exact cause and catch it before
it acts, have your child properly treated. When a sore throat persists,
seek medical attention from a doctor experienced in PANDAS. If your
child does have GABHS strep throat, as determined by a throat culture,
the symptoms of rheumatic fever could be prevented if a course of antibiotics
is taken within nine days of the onset of the infection. We believe
that it is important to put the child on specific nutrient supplements
that target brain structures and the right probiotics (beneficial bacteria)
to replace the ones that antibiotics kill in the gut.
Watch for changes in the child's
behaviours that are unexplained or out of character, such as mood changes,
clinginess, hyperactivity, inattentiveness, obsessive thoughts, checking
behaviours, repetitive noises or vocalisations, poor muscle control
or coordination, ants in the pants movements or even new-onset bedwetting.
At this time, this constellation of symptoms is under research investigation
and it is not recommended that children with behaviour symptoms receive
long-term treatment with antibiotics.
PANDAS
treatment at the Behavioural Neurotherapy Clinic
When PANDAS is suspected due
to the diagnostic criteria being met, we hypothesise that a short period
on antibiotics (every time an episode of GABHS infection is confirmed)
concurrent with and followed by ongoing nutrient supplementation to
promote optimum Brain cell plasma membranes and Brain tissues may help
brain recovery and protect against the full development of serious chronic
psychiatric disorders.
Based on evidence that there is a recovery period (as the GABHS antibodies
reduce to normal) after the strep infection is over, we hypothesise
that helping the brain recover with nutrients may reduce vulnerability
to further damage by the strep antibodies. This is a commonsense approach
to a medical problem with no proven medical solutions as yet.
The case studies that we have gathered to-date at the clinic are encouraging.
Results of this approach show significant changes towards normal in
QEEG brainmapping and improvement in behaviours. Jacques Duff presented
this data at the International Society for Neuronal Regulation Scientific
Seminar in Sydney (Sept. 2004)
(Jacques Duff and
Dr. Joe Nastasi) |
|
Is there a test for PANDAS?
No. The diagnosis of PANDAS
is a clinical diagnosis, which means that there are no lab tests that
can diagnose PANDAS. Instead clinicians use 5 diagnostic criteria for
the diagnosis of PANDAS (see below). At the present time the clinical
features of the illness are the only means of determining whether or
not a child might have PANDAS.
What are the diagnostic criteria
for PANDAS?
Pandas is diagnosed if there
is an episodic history of the following symptoms associated with strep
infections.
- Presence of Obsessive-compulsive
disorder and/or a tic disorder, ADHD symptoms or oppositional behaviours
- Association with neurological
abnormalities (motor hyperactivity, or adventitious movements, such
as choreiform movements)
- Paediatric onset of symptoms
(age 3 years to puberty)
- Episodic course of symptom
severity. (symptoms come and go)
- Association with group A
Beta-hemolytic streptococcal infection (GABHS)
- GABHS evidenced by either
a positive throat culture for strep or positive for streptococcus serology
(ASOT or AntiDNAse-B)
- A history of Scarlet Fever
or Rheumatic fever
What is an episodic course
of symptoms?
Children with PANDAS seem to
have dramatic ups and downs in their OCD and/or tic severity. Tics or
OCD which are almost always present at a relatively consistent level
do not represent an episodic course. Many children with OCD or tics have
good days and bad days, or even good weeks and bad weeks. However, patients
with PANDAS have a very sudden onset or worsening of their symptoms,
followed by a slow, gradual improvement. If they get another strep.
infection, their symptoms suddenly worsen again. The increased symptom
severity usually persists for at least several weeks, but may last for
several months or longer. The tics or OCD then seem to gradually fade
away, and the children often enjoy a few weeks or several months without
problems. When they have another strep. throat infection the tics or
OCD or associated behaviours return just as suddenly and dramatically
as they did previously.
My child has had strep. throat before,
and he has tics and/or OCD. Does that mean he has PANDAS?
No. Many children have OCD and/or tics,
and almost all school aged children get strep. throat at some point
in their lives. Only when a child has a very episodic course of tics
and/or OCD and seems to have strep. throat shortly before or at the
time of a dramatic worsening of symptoms does this indicate the possibility
of PANDAS.
What does an elevated anti-streptococcal
antibody titer mean? Is this bad for my child?
An elevated anti-strep. titer (such
as an ASOT or an AntiDNAse-B) means the child has had a strep. infection
sometime within the past few months, and his body created antibodies
to fight the streptococcus bacteria. This is not bad. In fact it is
a normal, healthy response-- all healthy people create antibodies to
fight infections. The antibodies stay in the body for some time after
the infection is gone, but the amount of time that the antibodies persist
varies greatly between different individuals. Some children have "positive"
antibody titers for many months after a single infection. This means
that an elevated anti-streptococcal titer may have nothing to do with
the present worsening symptoms, but instead indicates a long-since healed
strep. throat.
Could an adult or teenager
have PANDAS?
By definition, PANDAS is a
paediatric disorder. It is possible that adolescents and adults may
have immune mediated OCD. Although the research studies at the NIMH are
restricted to PANDAS, there are a number of reported cases in the medical
literature of adolescent and adult onset OCD and TICS with GABHS and
even non-Haemolitic streptococcus infections.
Will Penicillin treat PANDAS?
No. Penicillin and other antibiotics
kill streptococcus and other types of bactera. The antibiotics treat
the sore throat or pharyngitis caused by the strep., by getting rid
of the bacteria. However, in PANDAS, it appears that antibodies produced
by the body in response to the strep. infection are the cause of the
problem, not the bacteria themselves. Therefore one could not expect
antibiotics such as penicillin to treat the symptoms of PANDAS.
Current research at the NIMH has been investigating
the use of antibiotics as a form of prophylaxis or prevention of future
problems. It is important to note however, that the success of antibiotic
prophylaxis for PANDAS patients has not yet been proven. Until its usefulness
is determined, penicillin and other antibiotics should NOT be used
as long-term treatment for OCD and tics. |