Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcus: Comparison of Diagnosis and Treatment in the Community and at a Specialty Clinic

Abstract

OBJECTIVES-This study aimed to examine whether pediatric autoimmune neuropsychiatric disorders associated with streptococcus were appropriately diagnosed in the community and to determine subsequent rates of unwarranted use of antibiotic treatment for tics and obsessivecompulsive symptoms without the identification of an infection. METHODS-The design was a retrospective, cross-sectional, observational study of 176 children and adolescents who were evaluated in a specialty program for tics, Tourette's disorder, and related problems. Previously published diagnostic criteria were used to establish the diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus in our clinic.RESULTS-Subjects were significantly less likely to receive a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus at the specialty clinic than in the community. In the community, subjects were significantly more likely to be treated with antibiotics or immunosuppressant medication if they received a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus. Of the 27 subjects with a community diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcus who were treated with antibiotics, 22 (82%) were treated without laboratory evidence of an infection; 2 were treated with immunomodulatory medications. CONCLUSIONS-Our results support our hypothesis that pediatric autoimmune neuropsychiatric disorders associated with streptococcus are frequently diagnosed in the community without the application of all working diagnostic criteria. This phenomenon has resulted in unwarranted use of antibiotic treatment for tics/obsessive-compulsive disorder without evidence of laboratory infection.

The Immunobiology of Tourette's Disorder, Pediatric Autoimmune Neuropsychiatric Disorders Associated withStreptococcus, and Related Disorders: A Way Forward

“…A recent examination of youth classified as PANDAS by their community physicians found that 61% did not strictly meet the NIH criteria for PANDAS (Gabbay et al 2008). During the history gathering process, careful attention should be given to reports of repeated, frequent infections; evidence of GAS in a young child (e.g., unexplained abdominal pain accompanied by fever); scarlet fever; brief episodes of tics; OCD or compulsive urination, which remitted; and especially sudden onset of OCD or tics accompanying an infectious illness.…”

“…Many children presenting with a PANDAS-like presentation do not have this level of documentation to support GAS infection. Rigorous application of full diagnostic criteria for PANDAS is not always employed in the community setting, and the practice of unwarranted use of antibiotics in children without objective laboratory evidence of infection could increase antibiotic resistance in the pediatric population (Gabbay et al 2008). It is this lack of a definitive diagnosis of GAS infection that lends to ambiguity and skepticism in establishing GAS relatedness to OCD/tic onset.…”

“…Other preliminary data support dysregulation in cellular proinflammatory mechanisms. Gabbay et al (2009) examined the potential role of cytokines in 32 children and adolescents with TD. Patients with comorbid OCD were found to have significantly elevated IL-12 plasma levels compared with controls, whereas IL-2 was significantly elevated in TD þ OCD subgroup compared with the TD À OCD subgroup.…”

“…PANDAS symptom improvement during antibiotic therapy is primarily expected to be secondary to antimicrobial effects, but the potential for multiple roles of penicillin (or other beta-lactam antibiotics) would open the door for other mechanisms in the PANDAS pathophysiology and treatment. The use of prophylactic antibiotics to treat PANDAS has become widespread in the community (Gabbay et al 2008), although the evidence supporting their use is equivocal Budman et al 2005;Snider et al 2005). The safety and efficacy of antibiotic therapy for patients meeting the PANDAS criteria needs to be determined in carefully designed trials.…”

Autoimmune neuropsychiatric disorders associated with infection

“…PANDAS could be a diagnosis that is not thought of acutely and GABHS are not routinely investigated or screened for in the community making unnecessary treatment with antibiotics more likely if a GABHS infection is presumed rather than confirmed. 12 The PANDAS diagnostic criteria also state that infection and the symptoms should be temporally related. 5 The temporal relationship between GABHS and symptom exacerbation can vary over the course of the illness and in cases of rheumatic fever there can be a delay of up to six to nine months between evidence of infection and the appearance of symptoms of Sydenham's chorea.…”