Research

Two Cases of Montelukast-Associated Psychosis in Children
Jumaili WA, Gburi NA, Chaudhary N, Brown K, Jain S. Two Cases of Montelukast-Associated Psychosis in Children. Prim Care Companion CNS Disord. 2024 May 28;26(3):23cr03694. doi: 10.4088/PCC.23cr03694. PMID: 38815271.
In 2020, the FDA issued a black box warning of severe mental health complications in children associated with montelukast use.1,2 Montelukast-induced dose dependent neuropsychiatric symptoms in children include depression, anxiety, irritability, sleep disturbance, nightmares, agitation, suicidal behavior, auditory/visual hallucinations, and/or full psychosis.1 Stopping montelukast treatment abruptly can have varying effects on underlying neuropsychiatric symptoms and may increase the likelihood of recurrence after restarting montelukast.1
Montelukast treatment has been linked to an increased risk of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).5 The correlation between montelukast therapy and PANDAS is not fully understood, but many streptococcal infections have occurred after discontinuing montelukast treatment.5
Implementing dietary changes with children affected by PANS/PANDAS

Khimani, Kynza & Abadía-Barrero, César & LaRusso, Maria. (2024). Implementing dietary changes with children affected by PANS/PANDAS. Children’s Health Care. 1-19. 10.1080/02739615.2024.2338763.

  • 64.7% of the 467 survey participants indicated that a healthcare provider recommended dietary changes as part of PANS/PANDAS treatment.
  • 55.7% of the families did implement dietary changes
  • 69.6% reported at least one diet to be somewhat effective in helping with PANS/PANDAS symptoms
  • 36% reported dietary changes to be very effective, particularly gluten-free and sugar-free diet
  • Some parents and clinicians highlighted children’s resistance to new diets and concerns about worsening OCD and food-restrictive disorders as barriers to implementing dietary changes

 

 

Inflammation as the Common Pathophysiology Linking Stress, Mental Illness, Autoimmunity and Chronic Disease: Implications for Public Health Policy

Kinderlehrer DA. Inflammation as the Common Pathophysiology Linking Stress, Mental Illness, Autoimmunity and Chronic Disease: Implications for Public Health Policy. J Biomed Res Environ Sci. 2024 Mar 28; 5(3): 242-255. doi: 10.37871/jbres1889, Article ID: JBRES1889, Available at: https://www.jelsciences.com/articles/jbres1889.pdf

  • The article discusses the interplay between genetics, epigenetics, stress, trauma, inflammation, mental illness, autoimmunity, and chronic disease.
  • While modern medicine has made significant advances in disease care,
    it appears that lifestyle intervention, early childhood intervention, and socioeconomic
    investment and have the potential to make an even greater impact on the mental and
    physical well-being of the population.
  • An individual’s genetic makeup influences susceptibility to conditions, but environmental factors like stress and trauma can modify this through epigenetics.
  • Chronic stress and trauma can induce epigenetic changes and dysregulate immune responses, leading to inflammation, mental illness, autoimmunity, and chronic disease.
  • Lifestyle changes like exercise, diet, and toxin management can reduce inflammation and risks of mental and physical illness. Stress is a key factor and reducing stress through mindfulness, meditation, and exercise can decrease inflammation. Loneliness is a significant stressor and healthy social connections are important.
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.
    Unmasking Bartonella henselae infection in the shadows of long COVID thanks to clinical metagenomics
    Aubry A, Corvilain E, Ghelfenstein-Ferreira T, Camelena F, Meignin V, Berçot B, Le Goff J, Salmona M. Unmasking Bartonella henselae infection in the shadows of long COVID thanks to clinical metagenomics. Eur J Clin Microbiol Infect Dis. 2024 May;43(5):1025-1029. doi: 10.1007/s10096-024-04801-2. Epub 2024 Mar 12. PMID: 38472519.
    This case study highlights how clinical metagenomics uncovered a hidden Bartonella henselae infection in a patient with long COVID symptoms. A 26-year-old woman, experiencing prolonged post-COVID symptoms, including axillary adenopathy, was diagnosed with bartonellosis after a biopsy revealed B. henselae DNA and RNA. Treatment with clarithromycin led to symptom improvement. The case emphasizes the importance of thorough investigation for hidden infections in long COVID, especially when encountering polyadenopathy, regardless of exposure to cats or fleas.
    PANDAS coexisting with gastrointestinal and cerebellar manifestation

    Aftab Ahmed, Fatima Bint Sajid, Zaib Un Nisa Mughal, Wajeeha Binte Sajid, Abdul Haseeb,
    PANDAS coexisting with gastrointestinal and cerebellar manifestation, Journal of Medicine, Surgery, and Public Health, Volume 2, 2024,100086, ISSN 2949-916X, DOI: /10.1016/j.glmedi.2024.100086.

    We wish to bring attention to the importance of PANDAS in pediatric patients, as it can have a detrimental impact on their academic and social development. The scarcity of PANDAS cases in Pakistan may be attributed due to lack of awareness and interdisciplinary communication. Enhanced cross-referral between pediatricians and psychiatrists can help alleviate the morbidity and disability associated with this condition. This case highlights the need to recognize atypical PANDAS presentations that exhibit unique neurological and gastrointestinal symptoms. A multidisciplinary approach is crucial for accurate diagnosis and effective management in these intricate cases.

    Silent Infections are not So Silent: The Emerging Role of Combined Infections, Inflammation, and Vitamin Levels in OCD
    Marazziti D, Massa L, Carbone MG, Palermo S, Arone A, D’Angelo G, Schulz Bizzozzero Crivelli N, Gurrieri R, Perrone P, Palagini L, Dell’Osso L. Silent Infections are not So Silent: The Emerging Role of Combined Infections, Inflammation, and Vitamin Levels in OCD. Clin Neuropsychiatry. 2024 Feb;21(1):7-21. doi: 10.36131/cnfioritieditore20240101. PMID: 38559435; PMCID: PMC10979795.

    Conclusions: 

    • The findings of our study show an association between Epstein-Barr infection and hypovitaminosis D and the overall severity and specific symptom patterns of OCD.
    • The laboratory measures used in this study are useful, cheap and easy parameters that should be routinely assessed in patients with OCD.
    • Further studies are needed to clarify their role in OCD pathophysiology and outcomes, as well as the potential therapeutic impact of vitamins and antibiotics/immunomodulatory agents in OCD and other psychiatric conditions.
    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.
    Baseline characteristics of children in the International PANS Registry (IPR) Epidemiology Study
    Masterson EE, Gavin JM. Baseline characteristics of children in the International PANS Registry (IPR) Epidemiology Study. BMJ Open. 2024 Jan 24;14(1):e072743. doi: 10.1136/bmjopen-2023-072743. PMID: 38267248; PMCID: PMC10824037.
      • Participants & Household Composition: 1,781 individuals (1,179 cases, 602 siblings) from 1,010 households; 39% include a sibling, and 20% have multiple cases.
      • Enrollment Age: Mean age was 11.3 years for cases and 10.1 years for siblings.
      • PANS-like Features: Anxiety (94%), emotional lability (92%), and obsessions (90%) were the most common symptoms.
      • Onset Patterns: 95% had a sudden or dramatic onset, either initially or following gradual progression; early signs began around age 4, with dramatic increases around age 7.
      • Symptom Triggers & Treatment: Infection/illness triggered symptoms in 84% of cases; 88% were treated with antibiotics and 79% with NSAIDs.
      • Immune-related Conditions: Reported in 18% of cases and 48% of nuclear, biological families, with 39% in biological mothers.
    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