Are There Neuropsychiatric and Behavioral Sequelae of Group A, betahemolytic Streptococcus?: The First Ever Prospective Cohort Study to Examine PANDAS Symptomatology
Creators: name: Perrin, Eliana Miller, MD
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2002

description: Background: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) has been described in the literature to define a subset of children with Obsessive Compulsive Disease (OCD) and/or tic disorders whose neuropsychiatric symptoms begin following a streptococcal pharyngeal infection, most likely as a result of an auto-immune process. The existence of the entity remains controversial. Post-streptococcal neuropsychiatric sequelae have never been studied prospectively with a comparison group or in an outpatient pediatrics setting. Aims: I) To further assess the association between Group A beta-hemolytic strep (GABBS) and neuropsychiatric symptoms to detennine if the exposure of strep throat confers a risk (not explained by stress itself) to the development of neuropsychiatric symptoms as described by parents and the children themselves. 2) If GABBS is found to be associated with neuropsychiatric sequelae, to determine the incidence of post-streptococcal neuropsychiatric and abnormal behavioral symptoms in an outpatient pediatrics practice and to categorize by symptom type the most common neuropsychiatric or behavioral sequelae. Methods: Subjects were 796 sick and well children (age 4-11) without psychiatric or neurological disease from an outpatient pediatrics practice in upstate New York and their primary care takers. At time of emollment: I) all children received a throat culture testing for GABBS; 2) parents were administered a questionnaire that asked about demographics as well as the presence or absence of recent life stress for the child/family and presence or absence of recent symptoms of obsessive compulsive disease, tics, and other abnormal behavioral symptoms in their children; and 3) children who were able also completed a 10-item questionnaire about their own thoughts, obsessions, and compulsions. Children who cultured positive were treated with appropriate antibiotics. Two weeks and 11 weeks after enrollment, parents and children were sent the same questionnaires. The final cohort included 370 children with strep throat (exposed), and 426 children without strep throat (unexposed, 205 of whom were healthy and 22lof whom presented with symptoms of illness). Two-sample t-tests were used to determine whether the mean number of survey question endorsements were different at time of enrollment and at time of follow-up in the exposed vs. the unexposed groups. Non-parametric testing was used for skewed samples. Risk ratios for individual symptoms were calculated to compare the risk of exposure versus nonexposure to GABHS. Pearson's chi-square tests were performed to determine if the exposed versus the unexposed differed for each of the three groups of symptoms (OCD, tics, or abnormal behaviors not specified). The incidence of a PANDAS-like syndrome was calculated for this cohort based on a dichotomous outcome of a statistically significantly elevated number of symptoms present at follow up that were not present at enrollment. Results: Parents whose children had throats that cultured positive for GABHS reported a higher mean number of neuropsychiatric and abnormal behavioral symptoms than parents whose children were strep negative (plt;O.O 1 ). RR of streptococcal exposure and three PANDAS symptoms are as follows: frequent hand-washing RR= 2.8 (95% CI 1.4-3.4); frequent checking RR=2.2 (95% CI 1.2-3.1); and unusual separation anxiety RR= 3.1 (95% CI 1.8-4.7). Post-streptococcal sequelae were most likely to represent the OCD-like spectrum and abnormal behaviors not specified (p=O.Ol, and p=0.03, respectively) with a trend toward tic-like disorders. The incidence of a PANDAS-like syndrome in this outpatient practice cohort was lO cases per 370 exposed patients who were enrolled (2.7% ). Importance: The first prospective study of children to examine post-streptococcal neuropsychiatric and abnormal behavioral symptoms has shown that children exposed to GABHS do have increased symptoms when compared to both sick and well children without strep throat. This research adds strong support to a growing body of literature indicating a post-infectious pathophysiology for psychiatric symptomatology. Such findings may contribute to future abilities to curb disabling psychiatric symptoms in children.