P.A.N.D.A.S.

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P.A.N.D.A.S. is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections, a hypothesized condition describing a subset of children who have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette syndrome, and in whom symptoms are believed to worsen following strep infections such as "strep throat" and scarlet fever.[1]

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[edit] Symptoms

Children with PANDAS are clinically identified by dramatic, "overnight" onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions,[1] although this has not been consistent in all studies. Indeed some studies have shown no acute motor exacerbations among clinically defined PANDAS subjects[2][3][4][5] whilst others have shown a profound one.

In addition to the motor symptoms, it is also thought that children may have psychiatric manifestations, becoming moody, irritable or show concerns about separating from parents or loved ones.[1] This abrupt onset is hypothesized to be preceded by a strep throat infection. The clinical spectrum of PANDAS appears to resemble that of Tourette's syndrome which has lead some researchers to hypothesize that PANDAS and Tourette's may have some association, although this is highly speculative and controversial.

[edit] Mechanism

At present, the mechanism (pathophysiology) behind this infection is unknown but researchers at the NIMH are pursuing a theory that the mechanism is similar to that of rheumatic fever, an autoimmune disorder triggered by a reaction to the antibodies to streptococcal infections, in which these antibodies attack similar regions of the brain that are affected in some neuropsychiatric conditions. In every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However in rheumatic fever, the antibodies mistakenly recognize and "attack" the heart valves, joints, and/or certain parts of the brain. This phenomenon is called "molecular mimicry", which means that proteins on the cell wall of the strep. bacteria are similar in some way to the proteins of the heart valve, joints, or brain. Because the antibodies set off an immune reaction which damages those tissues, the child with rheumatic fever can get heart disease (especially mitral valve regurgitation), arthritis, and/or abnormal movements known as Sydenham's chorea or Tourette syndrome.[1]

In PANDAS, it is believed that something very similar to Tourette syndrome occurs. One part of the brain that is affected in PANDAS is the basal ganglia, which is believed to be responsible for movement and behavior. Thus, the antibodies interact with the brain to cause tics and/or OCD, instead of Tourette syndrome.

[edit] Controversy

The PANDAS theory is a highly controversial, unproven hypothesis.[3][6][7][8][9] It has engendered the use of controversial, dangerous and unproven treatment methodologies for children with tics and OCD, such as intravenous immunoglobulin (IVIG),[10] plasma exchange, and the use of prophylactic antibiotics for the prevention of streptococcal infections. The Advisory Boards of the Tourette Syndrome Association issued a joint warning, with the NIH, about the use of these unproven methodologies.[11]

[edit] Notes

  1. ^ a b c d NIH. PANDAS. Retrieved 25 November 2006.
  2. ^ Singer HS, Hong JJ, Yoon DY, Williams PN. Serum autoantibodies do not differentiate PANDAS and Tourette syndrome from controls. Neurology. 2005 Dec 13;65(11):1701-7. PMID 16207842
  3. ^ a b Luo F, Leckman JF, Katsovich L, Findley D, Grantz H, Tucker DM, Lombroso PJ, King RA, Bessen DE. Prospective longitudinal study of children with tic disorders and/or obsessive-compulsive disorder: relationship of symptom exacerbations to newly acquired streptococcal infections. Pediatrics. 2004 Jun;113(6):e578-85. PMID 15173540
  4. ^ Loiselle CR, Wendlandt JT, Rohde CA, et al. Antistreptococcal, neuronal, and nuclear antibodies in Tourette syndrome. Pediatr Neurol. 2003 Feb;28(2):119-25. PMID 12699862
  5. ^ Loiselle CR, Lee O, Moran TH, Singer HS. Striatal microinfusion of Tourette syndrome and PANDAS sera: failure to induce behavioral changes. Mov Disord. 2004 Apr;19(4):390-6. PMID 15077236
  6. ^ Singer HS, Loiselle C. PANDAS: a commentary. J Psychosom Res. 2003 Jul;55(1):31-9. PMID 12842229
  7. ^ Kurlan R, Kaplan EL. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004 Apr;113(4):883-6. PMID 15060240 Full-text.
  8. ^ Dale RC. Post-streptococcal autoimmune disorders of the central nervous system. Dev Med Child Neurol. 2005 Nov;47(11):785-91. Review. PMID 16225745
  9. ^ John Hopkins Medicine. A Strep - Tourette Connection? Brain Waves Fall 2004 Volume 16, Number 4. Retrieved 25 November 2006.
  10. ^ Hoekstra PJ, Minderaa RB, Kallenberg CG. Lack of effect of intravenous immunoglobulins on tics: a double-blind placebo-controlled study. J Clin Psychiatry. 2004 Apr;65(4):537-42. PMID 15119917
  11. ^ Franklin, Deeanna. Warning About Two Therapies for Tourette's, OCD - obsessive-compulsive disorder. Family Pratice News, Sept 15, 2000. Retrieved 25 November 2006.
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