Research

Enuresis as a presentation of Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS)

Poster: Enuresis as a presentation of Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS)

Author: Ying Xin Wong, Ubhi Tim

Presented: The Royal College of Paediatrics and Child Health Annual Meeting, March 2023.

  • Out of the total cohort of 109 children, 56 patients (51%) had enuresis as a presenting symptom alongside their PANDAS symptoms.
  • Enuresis is a common presentation of children with PANDAS (observed in 51% of cases). Early recognition of enuresis is important in promptly identifying PANDAS cases allowing prompt investigation and treatment.
    Postacute Sequelae of SARS-CoV-2 in Children

    Suchitra Rao, MBBS, MSCS; Rachel S. Gross, MD, MS; Sindhu Mohandas, MD; Cheryl R. Stein, PhD; Abigail Case, MD; Benard Dreyer, MD; Nathan M. Pajor, MD; H. Timothy Bunnell, PhD; David Warburton, MD; Elizabeth Berg, MD; Jonathan B. Overdevest, MD; Mark Gorelik, MD; Joshua Milner, MD; Sejal Saxena, BA; Ravi Jhaveri, MD; John C. Wood, MD, PhD; Kyung E. Rhee, MD, MSc, MA; Rebecca Letts, BA; Christine Maughan, BS; Nick Guthe, BA; Leah Castro-Baucom, MA; Melissa S. Stockwell, MD, MPH. Postacute Sequelae of SARS-CoV-2 in Children. AAP Publications, Feb 7, 2024, https://doi.org/10.1542/peds.2023-062570

    • The COVID-19 pandemic has had far-reaching impacts on health, society, and the economy, with some individuals experiencing lingering effects beyond the acute phase.
    • Emerging data on post-acute sequelae of SARS-CoV-2 infection (PASC) in children, or long COVID, is shedding light on persistent symptoms, new manifestations, and exacerbation of underlying conditions.
    • Children may develop new conditions such as postural orthostatic tachycardia syndrome (POTS), myalgic encephalomyelitis/chronic fatigue syndrome, autoimmune conditions, and multisystem inflammatory syndrome in children.
    • The review summarizes current knowledge on PASC in children, including its children, prevalence, epidemiology, risk factors, clinical characteristics, underlying mechanisms, and functional outcomes. It presents a framework based on NIH-funded research to understand PASC’s effect on children and young adults to guide treatments and prevention efforts. This research uses electronic health records and longitudinal studies to evaluate disease impact, progression, and clinical outcomes.

    Section on Mental Health

    • The COVID-19 pandemic resulted in multiple mental health conditions among children, including anxiety, stress, depression, panic, irritability, impulsivity, sleep problems, emotional lability, posttraumatic stress disorder, eating disorders, and suicidal behavior.
      Research is needed to understand whether these conditions are directly related to the virus or influenced by pandemic-related factors like social distancing and school closures.
    • Large EHR cohort studies have shown a higher incidence of neurologic or psychiatric diagnoses in children in the 6 months after SARS-CoV-2 compared with those without confirmed infection.
    • A COVID-19 diagnosis is associated with experiencing a new mental health condition (within a median of 33 days after infection) compared with negative controls in children.
    • The common mental health issues seen in children post-COVID-19 infection are anxiety, attention-deficit/hyperactivity disorder, and trauma-related disorders. Additionally, there are reports of acute-onset neuropsychiatric syndrome in children following COVID-19 infection.
    • There have also been case reports of pediatric acute-onset neuropsychiatric syndrome in children after SARS-CoV-2 infection.72,73 
    Folate Receptor Alpha Autoantibodies in the Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Population

    Wells L, O’Hara N, Frye RE, Hullavard N, Smith E. Folate Receptor Alpha Autoantibodies in the Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Population. Journal of Personalized Medicine. 2024; 14(2):166. https://doi.org/10.3390/jpm14020166

    Folate receptor alpha autoantibodies (FRAAs) are linked to two conditions: cerebral folate deficiency (CFD) and autism spectrum disorder (ASD). These conditions share similarities with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS).

    • The research suggests that FRAAs might play a role in PANS/PANDAS symptoms.
    • Blood samples from 47 young patients diagnosed with PANS/PANDAS were sent for FRAA analysis.
    • 63.8% of these patients had FRAAs, with various types present.
    • Surprisingly, lower FRAA levels were associated with ASD, while higher levels were linked to severe tics.
    • A case study shows treatment with leucovorin improved symptoms in a FRAA-positive PANS/PANDAS patient.
    • These findings suggest that FRAAs are linked to PANS/PANDAS and that issues with folate metabolism might contribute to symptoms. Further research on leucovorin’s potential in treating PANS/PANDAS is necessary, offering a promising alternative treatment option
    Sensory processing in children with Paediatric Acute-onset Neuropsychiatric Syndrome
    Newby, M. J., Lane, S. J., Haracz, K., Tona, J., Palazzi, K., & Lambkin, D. (2024). Sensory processing in children with Paediatric Acute-onset Neuropsychiatric Syndrome. Australian Occupational Therapy Journal, 1–11. https://doi.org/10.1111/1440-1630.12935
    Conclusion:
    • Children with PANS experience significant sensory reactivity differences during exacerbation and remission across multiple sensory domains, with a decline in performance during exacerbation.
    • Where occupational performance challenges exist, occupational therapists should consider administering sensory assessments so that effective intervention plans can be developed to address the unique sensory reactivity needs of children with PANS.
    Case report: Diagnosis and intervention of a non-24-h sleep–wake disorder in a sighted child with a psychiatric disorder

    Carla Estivill-Domènech, Carla Estivill-Domènech. Case report: Diagnosis and intervention of a non-24-h sleep–wake disorder in a sighted child with a psychiatric disorder. Front. Psychiatry, 05 January 2024. Sec. Sleep Disorders. Volume 14 – 2023 | https://doi.org/10.3389/fpsyt.2023.1129153

    Overview:

    • Circadian Rhythm Sleep-Wake Disorders (CRSWD) are sleep issues linked to circadian function. These disorders cause insomnia or excessive sleepiness due to the circadian pacemaker not aligning with a 24-hour light/dark cycle. Free-running disorder or Hypernycthemeral Syndrome (N24SWD) leads to a prolonged sleep-wake cycle, often seen in blind individuals. N24SWD is rare among those with healthy vision but affects 70% of blind individuals. In sighted cases, it mostly occurs in young men (80%), with 28% having a psychiatric disorder.

    Specific Case:

    • The patient, a 14-year-old boy with psychiatric pathology and PANDAS syndrome, experienced sudden intense anxiety, mood swings, and obsessive-compulsive-like issues associated with a streptococcal A infection. He also had a non-24-hour sleep-wake disorder (N24SWD), leading to severe insomnia and irregular sleep patterns.
    • The patient’s irregular sleep pattern worsened daily routines, including school attendance, and exacerbated psychiatric symptoms.
    • The association of PANDAS and N24SWD in the same case is unique and not previously reported in the literature.

    Treatment:

    • The initial treatment focused on acute infection and psychiatric symptoms.
    • Sleep pathology was addressed with light therapy and melatonin.
    • After 8 months of various trials, a treatment plan normalized symptoms, established a regular sleep pattern, and reduced daytime anxious symptoms
      Tafenoquine-Atovaquone Combination Achieves Radical Cure and Confers Sterile Immunity in Experimental Models of Human Babesiosis

      Pratap Vydyam, Anasuya C Pal, Isaline Renard, Meenal Chand, Vandana Kumari, Joseph C Gennaro, Choukri Ben Mamoun, Tafenoquine-Atovaquone Combination Achieves Radical Cure and Confers Sterile Immunity in Experimental Models of Human Babesiosis, The Journal of Infectious Diseases, 2024;, jiad315, https://doi.org/10.1093/infdis/jiad315

      • The 8-aminoquinoline antimalarial drug tafenoquine inhibits the growth of different Babesia species in vitro, is highly effective against Babesia microti and Babesia duncani in mice and protects animals from lethal infection caused by atovaquone-sensitive and -resistant B. duncani strains.
      • A combination of tafenoquine and atovaquone achieves cure with no recrudescence in both models of human babesiosis.
      • The elimination of B. duncani infection in animals following drug treatment also confers immunity to subsequent challenge.
      • The data demonstrate superior efficacy of tafenoquine plus atovaquone combination over current therapies for the treatment of human babesiosis and highlight its potential in providing protective immunity against Babesia following parasite clearance.
      Microbes and Mental Illness: Past, Present, and Future
      Bransfield RC, Mao C, Greenberg R. Microbes and Mental Illness: Past, Present, and Future. Healthcare (Basel). 2023 Dec 29;12(1):83. doi: 10.3390/healthcare12010083. PMID: 38200989; PMCID: PMC10779437.

      The review highlights five infectious diseases linked to mental illness: toxoplasmosis, COVID-19, Lyme borreliosis, and streptococcal infections/PANDAS/PANS. It emphasizes the significant role of indirect infection mechanisms, such as inflammation, neuroinflammation, autoimmunity, and neurophysiological changes, in the development and progression of some mental illnesses. The persistence of these processes can lead to chronic effects on brain structure and function. Recognizing the microbial impact on mental health is crucial, and understanding this association may lead to increased use of antimicrobial and immune-modulating agents in psychiatric treatment, preventing and reducing mental illness morbidity, disability, and mortality. Clinicians must consider infectious diseases in explaining mental health symptoms, especially in cases of treatment-resistant conditions.

      Treatment approaches must be individualized and often involve a multidisciplinary strategy to include three fundamental areas: addressing infections or contributors, implementing immune interventions, and managing resulting symptoms. Intervention choices depend on understanding the disease process, the interplay of disease contributors, and the primary driver of disease perpetuation and progression. Consider antimicrobials in cases of inadequate psychotropic response and potential infection. Immune-modulating interventions may be necessary for immune-mediated symptoms from active or prior infections or non-infection immune provocation. Factors like immune suppression, excessive inflammation, autoimmunity, and adaptive immunity failure influence immune intervention choices. Non-infection environmental factors, including toxin exposure, should be considered and minimized. For relapses, revisit effective past treatments; treatment-resistant cases may require exploring unused options. Regular treatment revisions are essential, guided by symptom improvement or disease changes. Ongoing assessment is crucial, recognizing that the initial cause may differ from what perpetuates the condition, leading to necessary treatment approach adjustments.

       

       

      Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Syndrome: A 10-Year Retrospective Cohort Study in an Italian Centre of Pediatric Rheumatology

      La Bella S, Attanasi M, Di Ludovico A, Scorrano G, Mainieri F, Ciarelli F, Lauriola F, Silvestrini L, Girlando V, Chiarelli F, et al. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Syndrome: A 10-Year Retrospective Cohort Study in an Italian Centre of Pediatric Rheumatology. Microorganisms. 2024; 12(1):8. https://doi.org/10.3390/microorganisms12010008

      PANDAS syndrome, a rare condition in prepubertal children, presents with sudden tic disorders and/or OCD following a documented GAS infection. Current classification criteria lack specificity, resulting in misdiagnosis. In our study, 61 patients were screened by the Pediatric Rheumatology unit for suspected PANDAS, but only 19 met the criteria. Tic disorders, especially in the eyes and head/neck, were predominant, with common vocal tics and less documented OCD. Treatment with antibiotics often led to clinical improvement. Larger, controlled studies are essential to understanding PANDAS characteristics and therapeutic responses comprehensively.

      The Intricate Dance of Infections and Autoimmunity: An Interesting Paradox

      Rao, A.P., Patro, D. The Intricate Dance of Infections and Autoimmunity: An Interesting Paradox. Indian J Pediatr (2023). https://doi.org/10.1007/s12098-023-04928-8

      Besides genetic susceptibility, infections due to viruses, bacteria and protozoa have been implicated in the development of autoimmune diseases (AD). AD can be triggered in a genetically susceptible individual by infections that disrupt immunological tolerance towards self-antigens. Pathogens can initiate autoimmunity by way of molecular mimicry, bystander activation, epitope spreading or persistent infection with polyclonal activation. This review covers two main topics: (i) the mechanisms by which an infectious agent can trigger or worsen autoimmunity; and (ii) the correlation between specific infectious agents and AD in humans with special emphasis on multisystem inflammatory syndrome in children (MIS-C).

      Caregiver Burden, Stress, and Relationship Cohesion Among Self-Identified Caregivers of Children with PANS
      Tona JT, Ash J, Brown E, Campagna C, Kostek K, Lawton E, Rieth A, Tomita M. Caregiver Burden, Stress, and Relationship Cohesion Among Self-Identified Caregivers of Children with Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol. 2023 Nov;33(9):378-386. doi: 10.1089/cap.2023.0030. PMID: 37966363; PMCID: PMC10771873.
      • Among the 216 respondents, 79.6% exceeded the CBI threshold, indicating a need for respite in adult care receiver populations. On the CSAQ, 72.9% expressed high distress, 80.5% reported feeling overwhelmed, and 58.1% reported crying spells, meeting cutoffs for support/respite used in adult care receiver populations.
      • The majority of caregivers (85.5%) reported not having the desired degree of cohesion with their child on the IOS. Parents of children with more severe PNSS symptoms performed significantly worse on all measures (CBI: H = 57.83; CSAQ: F = 29.26; IOS: H = 38.04; p < 0.001 for all).

      Common Comment Themes

      1. Severe caregiver and/or family emotional distress and trauma.
      2. Caregivers wondering what happened to their child.
      3. Lack of awareness and support among health and education professionals.
      4. Relationship strain with family, friends, and significant others.
      5. Financial and/or legal struggles due to their child’s diagnosis.

      “Conclusion: There is strong need for support and respite for children with PANS and their families. Long-term effects including posttraumatic stress symptoms among family members should be studied.”

      An updated review of pediatric autoimmune neuropsychiatric disorders associated with Streptococcus/pediatric acute-onset neuropsychiatric syndrome, also known as idiopathic autoimmune encephalitis: What the allergist should know
      Hardin H, Shao W, Bernstein JA. An updated review of pediatric autoimmune neuropsychiatric disorders associated with Streptococcus/pediatric acute-onset neuropsychiatric syndrome, also known as idiopathic autoimmune encephalitis: What the allergist should know. Ann Allergy Asthma Immunol. 2023 Nov;131(5):567-575. doi: 10.1016/j.anai.2023.08.022. Epub 2023 Aug 25. PMID: 37634580.

      Conclusion: Owing to the complexity and variability in ways patients with IAE may present to the allergist/immunologist office, an interdisciplinary approach is imperative to provide patients with the best medical care. Still, more research is needed to further elucidate the mechanism(s) and optimal treatment algorithm for IAE to facilitate broader recognition and acceptance of this condition by the medical community.