Can Strep Throat Lead to Behavior Problems?

MARCH 19, 2010, 12:31 PM New york times

Can Strep Throat Lead to Behavior Problems?

By THE NEW YORK TIMES

Can a bout of strep throat lead to serious behavioral problems like obsessive hand washing or odd tics in children?

Steve Kagan for The New York Times Obsessive hand washing sometimes follows strep infections; are the two related?

The condition, known as Pandas, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, remains a controversial topic among child health experts. Dr. Robert King and Dr. James Leckman of the Yale Child Study Center, who recently joined the Consults blog to answer readers’ questions about Tourette’s syndrome, here respond to readers concerned about the link between strep tics and obsessive-compulsive disorders.

Q.

RS from N.J. writes:

If your child shows symptoms of a tic disorder, obsessive-compulsive disorder or Tourette’s syndrome, you should have them checked for strep. Pandas, could be the cause. A simple blood test will tell if your child’s “strep titers” are at an abnormal level.

This can be treated with antibiotics. Worth checking out before you subject your child to psychiatric medications. Not all doctors believe in Pands. But let me tell you, it’s worth finding a doctor who does.

For more info check out the Web site Saving Sammy: Curing the Boy Who Got O.C.D.

Q.

Bethany Brinton from Salt Lake City asks:

The first sign of scarlet fever is obsessive hand washing, hours before the rash; Tourette’s is in the strep/O.C.D. family, or Panda. Why don’t they treat it with I.V. antibiotics and probiotics?

A.

Dr. King and Dr. Leckman respond:

Pandas, or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, remains a controversial topic for many experts in Tourette’s.

Two recently completed intensive longitudinal studies found little evidence to support the existence of Pandas as presently defined. Since the onset of tics is common in middle childhood and as many as half of young school age children may have strep throat in a given year, the co-occurrence of new tics and a strep infection will happen as mere coincidence, without any specific causal link, in a certain number of children.

Furthermore, since stress, including the stress of illness, can be a cause of tic flare-ups, it is not always clear if or when there is a more specific causal link.

That said, some researchers, including ourselves, suspect that the label of Pandas is probably best reserved for a subset of children with apparently strep-related O.C.D. or tics, and that it is this subset of cases that need to be more intensively studied. Such cases probably fall on a continuum with Sydenham’s chorea and other post-infectious disorders that can lead to an inflammation in the basal ganglia, a part of the brain involved in motor control and learning.

These more narrowly defined Pandas cases appear to have an abrupt sudden onset, over the course of two days or less, and are marked by separation anxiety and obsessive-compulsive symptoms, a loss of writing skills and sleep problems. Tics are often present, but they can also confuse the picture, especially if they had been present in some form prior to Pandas onset.

The overuse of antibiotics has its hazards, both for individuals and communities, including allergic reactions and fostering the development of antibiotic-resistant strains of bacteria. Hence, antibiotics — and certainly intravenous antibiotics — are not indicated for the typical case of tic disorder but should be reserved for cases where there is clear-cut and convincing evidence that the onset or recurrent flare-up of tics/O.C.D. is linked to strep infection.

Although there is at least one well done study that supports the use of intravenous immunoglobulin for well-defined Pandas cases, this work needs to be replicated. Plans are now under way for such a replication study in a carefully defined group of children who meet the narrower criteria described above; the study will again be performed at the National Institutes of Health’s Clinical Center in Bethesda, Md., by Dr. Susan Swedo, who first coined the term Pandas more than a decade ago.

Q.

mlw from Brooklyn asks:

What percentage of children could be misdiagnosed as Tourette’s and actually have Pandas?

A.

Dr. King and Dr. Leckman respond:

Another great question. Once we have a reliable and valid way of making a diagnosis of Pandas, we should be able to provide an answer.

As noted above, there is much controversy as to whether Pandas exist and, if so, how should they be defined. At present, in making a Pandas diagnsosis, we focus much more on the sudden, abrupt onset — unusually in less than 48 hours — of severe anxiety, obsessive-compulsive symptoms, sleep problems and behavioral regression and a marked deterioration of writing and drawing abilities. Tics may be present, but they are probably not a key feature.

I am happy to see a major newspaper covering this again. My BFF told me about Saving Sammy, a must read. It's fascinating how the medical community continues to be divided over the viability of a P.A.N.D.A.S. diagnosis. Must be about money. Or the fact there is no one-size-fits all. When will they get there is no such thing?

First week of 4th Grade, He's Catching On

D.C. shoes are IN for both kids. They look like giant puffy clown shoes to me, but I guess I'm not the one wearing them!

Leo and Sydney got on the bus the first day of school like it was a normal day from the spring. No real excitement or anticipation, just business as usual. I, on the other hand, was fine until the bus appeared over the little hill, and my eyes started to well up. Sydney, now in 2nd grade, looks at me while reaching out to touch my shoulder, and says"It'll be okay, Mom." Leo, now in 4th grade, dutifully leaned over for an A frame and off they went, leaving me confused as to where all the time went. I logically know, but man, it's still tough for me.

Sydney and Leo are in the mediocre grades at our schools, they are both considered repeat/reinforcer years. 1st, 3rd, and 5th are challenging and demanding, they throw all the new stuff at them in these grades and let the dust settle in between. I kind of like this strategy, should be a fairly easy year with not very much homework.

But back to the first week, Leo HATES school. Each day he says how absolutely boring it is, and honestly I can't blame him. Now that he's older, they go to lunch later, and they have their specials first thing in the morning, so the day isn't broken up much. He tells me that he tries not to look at the clock, and when he finally does, only 5 or 10 minutes have passed and it "just sucks, Mom." I've been there, and he's finally catching on to the rest of his life. The cheerleading cushy fun energetic times are over I think. But I do like his teacher, a sweet older man, his first male teacher. He's very old school, very ernest, a sports fan, and has a dry sense of humor. It's probably a good fit even though he's not that exciting.

Leo learned that an instrument was optional this year and they do weekly pullouts, he signed up for violin just to escape! I rented the instrument, so hopefully he'll actually enjoy but either way I'm covered. I can already hear the violin practice....

The social makeup looks very good this year. A nice group of boys in Leo's class, including his BFF. We are thrilled because this boy is a great friend in every way, they learn from each other, and we like the parents. Leo is playing AAA fall ball and is loving it per usual. Most of the same kids, some a blast from the past, really fun. He's learning to pitch now, I really like how they take turns playing ALL the positions. I still can't believe he can catch a ball let alone play organized ball sports by choice. Leo takes his football to school every day, and they play touch football games at recess. A nice group of boys that broke off from a large group that are more competitive and aggressive. A turnoff for Leo, but the good news is that he isn't alone with these sentiments. He's happy with his friends, I am estatic about this.

Sydney had a good start, then got a flu that had her miss an entire week of school. She was so sick, I thought for a while she may have had strep or even Lyme. I still think both my kids have some sort of suppressed Lyme based on their makeup of face tics and environmental sensitivities. Her tests came back negative, but they wouldn't test her for blood, which is what I really wanted to see about Lyme. But they wouldn't because she had abdominal symptoms which in theory are not Lyme. Such a hotly debated topic that I need to learn more about. The silver lining was this flu caused her chronic symptoms to get better. After 5 months of chronic tics that kept changing and coming back, she has been tic free for a week. In this house, we have bouts of wellness, so I can say she is now well, no chronic or acute illness!

I'm still working on Leo, he has a minor cold that's almost better, and his tics are minor, about 85% better. We are on our way, a remedy that in theory addressed his underlying root illness seems to be helping. I can put him back on his regular remedy soon and see what happens.

So far so good. I'm still waiting for two big things - the Yale writeup and the standardized testing results that should be mailed to us over the next couple of weeks. With these two instruments I should have something to go on to plan for Leo's future support.

As far as I go, I'm busy studying for my homeopathy degree and slowly updating my main website, www.hiddenrecovery.com, in hopes I can finally publish an article I've ignored for a very long time. I just need to do it. I am feeling pretty good about things these days, the kids seem happy which makes mom happy. I can't complain (well, other than about Sarah Palin or the economy crisis).

Strep Infection Doesn't Worsen Childhood Tics or OCD Symptoms

Oops, I forgot to post this when it came out....

Strep infection doesn't worsen childhood tics or OCD symptoms
by Will Boggs, MD

2008-06-16 13:29:56 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Streptococcal infection does not cause exacerbations of childhood tics or obsessive-compulsive symptoms, according to a report in the June issue of Pediatrics.

"This study provides further evidence against the use of chronic antibiotic or immune-suppressing therapy to treat these patients, as has been suggested," Dr. Roger Kurlan from University of Rochester School of Medicine, New York told Reuters Health.

"Patients meeting criteria for PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) seem to do fine with standard treatments for their symptoms of tics or obsessive-compulsive disorder (OCD)."

Dr. Kurlan and colleagues sought to determine whether there is a bona fide relationship between antecedent group A beta-hemolytic streptococcal (GABHS) infection and exacerbation of symptoms in 40 children who met the published diagnostic criteria for PANDAS, which included a temporal relationship between the course of illness and GABHS infection. These children were matched with 40 controls, who had OCD or a chronic tic.

Sixty-five clinical exacerbations occurred during the study; of these, 40 episodes occurred in 21 PANDAS children and 25 episodes were seen in 14 control children, the authors report, resulting in exacerbation rates of 0.56 per person-year for PANDAS children and 0.28 per person-year for control subjects.

PANDAS children, however, had more than three-times the GABHS infection rate than control children (0.43 versus 0.13 per person-year), the report indicates, and the higher risk of clinical exacerbation of tics or OCD for PANDAS children did not reach statistical significance.

Only 5 of the 64 total clinical exacerbations of tics and/or OCD occurred within 4 weeks of GABHS infection, and all 5 occurred in PANDAS subjects.

Based on a variety of time intervals and infection classifications, 75% to 92.5% of exacerbations in PANDAS children occurred with no observed evidence of a temporal relationship to GABHS infection, the investigators say.

"Our study results must be interpreted with caution," the researchers note, "because the number of clinical exacerbations and the number of GABHS infections observed were smaller than originally anticipated, particularly in control subjects."

"The most surprising result was that for children meeting criteria for PANDAS, so few of their exacerbations were linked to strep infection," Dr. Kurlan said.

"It remains unclear if the PANDAS hypothesis is true as presented," Dr. Kurlan concluded. In another trial the investigators "found no evidence of immune factors in association with clinical exacerbations in PANDAS cases, casting doubt on the autoimmune hypothesis."

Pediatrics 2008;121:1188-1197.

Copyright Reuters 2008.

This research is very interesting but doesn't convince me of no link. Obviously there IS a link in my own home and with the myriad of children I read about and see with my own eyes day after day in elementary classrooms. My children also do not meet the exact description of PANDAS as outlined by the Am. Academy of Pediatrics. Funny though, I thought the AAP didn't agree to a diagnostic criteria for PANDAS, referring to it only as a theory. Now in this publishing they refer to a criteria. Makes you wonder what is going on here. Bottom line is there are atypical responses to strep too numerous to ignore. Autoimmune reactions to strep, 5ths disease, Lyme, and many other illnesses is very disturbing and warrant immediate funding and attention. This is the future and it's obviously not going away.

I've written more posts on this topic. Also go to my Labels on the right and click on P.A.N.D.A.S. or strep.