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strep infection and PANDAS



 
 
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  #1  
Old April 16th 04, 02:18 AM
V.
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Default strep infection and PANDAS

I just came from an ADHD, OCD and Tourette's conference (I'm a social worker
for kids with mental illness), and the speaker talked a little about PANDAS,
which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated
with Streptococcal Infections. Basically, the idea is that newborns or
children who get strep, even if asymptomatic, may tend to get OCD, anxiety,
depression, etc. She made the statement that all pregnant women should be
screened for strep at 8 months, and treated with antibiotics. Further, she
stated that even if the woman then tests "clear" after treated for pos
strep, she should not have a vaginal birth (a bit extreme, I thought), but
if she did have a vaginal birth, it is still important to treat the baby
with antibiotics afterward (I thought a good point). Plus, kids should have
the strep culture done even if the "quick test" shows negative since it's
not always reliable, and kids don't always seem sick with strep. I just
thought mkp folks might be interested in the strep/psychiatric illness link,
since it was news to me!

Another note from the conference: she recommends that all pregnant or ttc
women have their mercury levels checked since it can vary from woman to
woman even with the same diet. If mercury is too high, flax seed oil can
help get it out of your system.

Who knew?
Amy
ttc #1


  #2  
Old April 16th 04, 03:51 AM
Ericka Kammerer
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Default strep infection and PANDAS

V. wrote:
I just came from an ADHD, OCD and Tourette's conference (I'm a social worker
for kids with mental illness), and the speaker talked a little about PANDAS,
which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated
with Streptococcal Infections. Basically, the idea is that newborns or
children who get strep, even if asymptomatic, may tend to get OCD, anxiety,
depression, etc. She made the statement that all pregnant women should be
screened for strep at 8 months,


Does she mean group B strep? Or what?

and treated with antibiotics. Further, she
stated that even if the woman then tests "clear" after treated for pos
strep, she should not have a vaginal birth (a bit extreme, I thought),


I should think so!

but
if she did have a vaginal birth, it is still important to treat the baby
with antibiotics afterward (I thought a good point).


But what about weighing that against the risk factors
of treating babies with antibiotics?

Plus, kids should have
the strep culture done even if the "quick test" shows negative since it's
not always reliable, and kids don't always seem sick with strep. I just
thought mkp folks might be interested in the strep/psychiatric illness link,
since it was news to me!

Another note from the conference: she recommends that all pregnant or ttc
women have their mercury levels checked since it can vary from woman to
woman even with the same diet. If mercury is too high, flax seed oil can
help get it out of your system.

Who knew?


Not me, that's for sure. A quick search didn't find
a *thing* supporting either of her recommendations in Medline
or anywhere else respectable, so I'd take this with a grain of
salt. It would be quite interesting if true, but I'm somewhat
skeptical at this point.

Best wishes,
Ericka

  #3  
Old April 16th 04, 04:21 PM
V.
external usenet poster
 
Posts: n/a
Default strep infection and PANDAS


"Ericka Kammerer" wrote in message
...
V. wrote:
I just came from an ADHD, OCD and Tourette's conference (I'm a social

worker
for kids with mental illness), and the speaker talked a little about

PANDAS,
which stands for Pediatric Autoimmune Neuropsychiatric Disorders

Associated
with Streptococcal Infections. Basically, the idea is that newborns or
children who get strep, even if asymptomatic, may tend to get OCD,

anxiety,
depression, etc. She made the statement that all pregnant women should

be
screened for strep at 8 months,


Does she mean group B strep? Or what?


Well, that wasn't overly clear at the conference. She specifically talked
about stories of children who developed OCD after strep throat infections,
and the research I found on Medline/Medscape talks about PANDAS and strep
_A_. I'll post a relevant article at the end of this post. (I don't want
to just post a link, 'cause you have to sign up for medscape and i don't
want people to have to do that) (Medscape is a pretty good resource though
for medical stuff)


and treated with antibiotics. Further, she
stated that even if the woman then tests "clear" after treated for pos
strep, she should not have a vaginal birth (a bit extreme, I thought),


I should think so!

but
if she did have a vaginal birth, it is still important to treat the baby
with antibiotics afterward (I thought a good point).


But what about weighing that against the risk factors
of treating babies with antibiotics?

Absolutely true. Her concern (she's a PhD, LPC who works in
neuropsychiatry) was about kids who have developed PANDAS after undetected
or repeated strep infections. I'm sure if she were an audiologist who
worked with kids who lost their hearing as a result of antiobiotic reaction,
she'd have a different perspective. (I also hope that if she were an OB/GYN
she'd have a different perspective about the no vaginal birth part too).

Plus, kids should have
the strep culture done even if the "quick test" shows negative since

it's
not always reliable, and kids don't always seem sick with strep. I just
thought mkp folks might be interested in the strep/psychiatric illness

link,
since it was news to me!

Another note from the conference: she recommends that all pregnant or

ttc
women have their mercury levels checked since it can vary from woman to
woman even with the same diet. If mercury is too high, flax seed oil

can
help get it out of your system.

Who knew?


Not me, that's for sure. A quick search didn't find
a *thing* supporting either of her recommendations in Medline
or anywhere else respectable, so I'd take this with a grain of
salt. It would be quite interesting if true, but I'm somewhat
skeptical at this point.

Best wishes,
Ericka


I think that the main message I got from this small part of the conference
(this was only a passing mention type of thing, but it seemed relevant to
mkp'ers) was that kids who develop OCD type symptoms should be checked for
strep, and families who have a history of OCD, etc. should be more aware of
potential symptoms being triggered post-strep. If anyone has experiences to
share about being tested pre-birth for strep A and their Dr's
recommendations, I'd appreciate it.

Regarding the mercury part, I can't seem to find anything about flax seed
oil either, although several other conference goers chimed in about how it
removed mercury as though it were some widely known fact. She had also just
finished talking about Omega 3 fatty acids, and the benefit of supplements
for kids with Asperger's, so I'm wondering if this is one of those things
that people believe without a lot of research to support it. You know,
"research shows that Omega 3 supplementation can benefit asperger's/autism"
and "research shows that high levels of mercury is correlated with
asperger/autism" _therefore_ "Omega 3 'must' remove mercury". Taking two
sets of research and coming up with a third unresearched statement.
Personally, I'm going to start taking fish oil supplements in order to
increase Omega 3 intake without the risk of mercury (Eating some fish is
good, it's just that eating a lot can cause high levels of mercury) I am
convinced by the research that typical American diets don't get enough Omega
3, and that Omega 3 is crucial in brain development, so I figure it probably
can't hurt. I'll probably avoid eating more than one can a week of canned
tuna, although I rarely have canned tuna, so that's no problem. I'll still
eat my usual fish/seafood whenever we go out (DH doesn't like it and he's
the chef), but I think that in order to get enough Omega 3 from diet alone
I'd have to eat it several times a week, and then I'd be ingesting too much
mercury.

So much to think about!
Amy V.
ttc #1


Article as promised
PANDAS in Children -- Current Approaches
Disclosures

Richard 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.
Susan 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-B). 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. Tanya
Murphy, 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.
William 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 Murphy 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. Murphy 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.. Murphy 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.. Murphy 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.. Murphy 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 http://www.nimh.nih.gov/events/pandaalert.cfm. Accessed November 15,
2002.
15.. Garvey MA, Perlmutter SJ, Allen AJ, et al. A pilot study of
penicillin prophylaxis for neuropsychiatic exacerbations triggered by
streptococcal infections. Biol Psychiatry. 1999;45:1564-1571.




Copyright 2002 Medscape.





  #4  
Old April 16th 04, 06:31 PM
Ericka Kammerer
external usenet poster
 
Posts: n/a
Default strep infection and PANDAS

V. wrote:


Does she mean group B strep? Or what?


Well, that wasn't overly clear at the conference. She specifically talked
about stories of children who developed OCD after strep throat infections,
and the research I found on Medline/Medscape talks about PANDAS and strep
_A_. I'll post a relevant article at the end of this post. (I don't want
to just post a link, 'cause you have to sign up for medscape and i don't
want people to have to do that) (Medscape is a pretty good resource though
for medical stuff)


Interesting article. I do think there are some interesting
things out there drawing some possible links between certain issues
and prior infections. I would just hope for some caution before
attempting to sentence a third or more women to c-sections! ;-)

Regarding the mercury part, I can't seem to find anything about flax seed
oil either, although several other conference goers chimed in about how it
removed mercury as though it were some widely known fact. She had also just
finished talking about Omega 3 fatty acids, and the benefit of supplements
for kids with Asperger's, so I'm wondering if this is one of those things
that people believe without a lot of research to support it. You know,
"research shows that Omega 3 supplementation can benefit asperger's/autism"
and "research shows that high levels of mercury is correlated with
asperger/autism" _therefore_ "Omega 3 'must' remove mercury". Taking two
sets of research and coming up with a third unresearched statement.


Yeah, you really have to wonder. If it were that easy
to get rid of mercury, I suspect there'd be a lot more talk ;-)

Personally, I'm going to start taking fish oil supplements in order to
increase Omega 3 intake without the risk of mercury


Yeah, I think that's probably a safe bet, though I'm
horrible about supplements, so I never seem to get around to it.

Best wishes,
Ericka

 




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