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VOL. 16, NO. 1, 2003

Clinical Case Report
Paediatric autoimmune neuropsychiatric disorders (PANDAS): A case report
INTRODUCTION Obsessive–compulsive disorders (OCD) are characterized by an onset in adolescence or early adulthood of recurrent obsessions and compulsions that are intense enough to cause marked discomfort. Several reports have suggested that autoimmune mechanisms play a role in the aetiology of OCD and Tourette’s syndrome in a subgroup of patients with early onset1–3 and a history of streptococcal throat infection. The acronym PANDAS was proposed to describe these paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection.2 Although b-haemolytic streptococcal infection is prevalent in India,4 we are not aware of any earlier report of PANDAS from the Indian subcontinent. We report a case of OCD who presented to us with features of PANDAS. THE CASE A 22-year-old unmarried man presented with a history of recurrent, unprovoked blasphemous thoughts against his parents and God since the age of 9 years, which were intrusive, irresistible and associated with intense guilt. However, he did not have any major functional impairment until he was 17 years old, when he had a sudden exacerbation of symptoms (associated with the stress of examinations), characterized by recurrent doubts about his ability to study and remember what he read, with a need to read repetitively. He also had other less prominent doubts regarding his ability in other activities (such as games) and blasphemous thoughts. Following this there was a remission in his symptoms until 6 months later when he had another sudden exacerbation. During the entire period, he recognized these thoughts as his own and as senseless. He had been an aboveaverage student at school and college, and had secured admission to a reputed professional institute. However, subsequent to his illness, he was forced to discontinue his studies. He gave a history of streptococcal throat infection at the age of 5 years for which he had received penicillin prophylaxis. Before consultation at our centre, he had received adequate trials with four specific anti-obsessional agents (fluoxetine up to 80 mg for 6 months, sertraline 100 mg for 2 months, clomipramine 250 mg for 6 months, and a course of fluoxetine 60 mg with risperidone 4 mg) including one augmentation strategy. As he had not shown adequate response to these, it was decided to give him fluvoxamine and augment it with psychological techniques. There was a family history of obsessive–compulsive personality traits in his father. On examination, he seemed fidgety and restless. There
Christian Medical College, Vellore 632002, Tamil Nadu, India A. SANKARANARAYANAN, J. K. JOHN Department of Psychiatry Correspondence to J. K. JOHN; © The National Medical Journal of India 2003

TABLE I. Criteria for the diagnosis of paediatric autoimmune neuropsychiatric disorders (PANDAS)2
1. Presence of a tic disorder, obsessive–compulsive disorder, or both, as per criteria established in the DSM-IV 2. Prepubertal onset of neuropsychiatric symptoms 3. History of sudden onset of symptoms, episodic course with abrupt symptom exacerbation interspersed with periods of partial or complete remission, or both 4. Evidence of a temporal association between onset of the neuropsychiatric symptoms and infection with group A beta-haemolytic streptococci (GABHS) 5. Adventitious movements (e.g. motor hyperactivity and choreiform movements) may be present during symptom exacerbation

was no evidence of a movement disorder. He had a positive antistreptolysin O (ASO) titre (400 units) earlier; at our hospital it was 84, which may have been due to the treatment he had received. In view of the early onset of obsessive symptoms with periodic sudden exacerbations interspersed with periods of partial remissions, and the past history of streptococcal throat infection, the possibility of PANDAS was considered (Table I). However, he did not exhibit any abnormal movement, although he seemed fidgety and restless (Swedo2 has described ‘squirminess’ in some patients). In addition, the ASO titre done at our hospital was negative. It is, however, well accepted that not all exacerbations are preceded by group A beta-haemolytic streptococci (GABHS) infections and a prospective follow up is required to establish this association. DISCUSSION Streptococci are among the most common disease-causing bacteria. This led to the concept that OCD might be a streptococcalinduced autoimmune reaction to brain antigens. Husby et al.5 demonstrated a cross-reaction between streptococcal and brain antigens. It has been suggested that in OCD following an infection, the antibodies to the bacteria may make their way to the healthy brain and attack the basal ganglia, which disrupts normal brain activity and triggers OCD. This report suggests that we need to be alert to the possibility of OCD arising secondary to GABHS infection, especially as the prevalence of streptococcal infection in India is high.6 This has possible therapeutic implications. It has been suggested that such patients could be given a trial of immunomodulator therapy such as plasmapharesis or intravenous immunoglobulins.6 Although still experimental, it may have potential for the future, especially in those not responding to conventional treatment. REFERENCES
1 Murphy TK, Petitto JM, Voeller KK, Goodman WK. Obsessive–compulsive disorder: Is there an association with childhood streptococcal infections and altered immune function? Semin Clin Neuropsychiatry 2001;6:266–76. 2 Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S, et al.

et al. 5 Husby G. Hamburger S.CLINICAL CASE REPORT Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: Clinical description of the first 50 cases. Attention Subscribers The subscriptions for The National Medical Journal of India are being serviced from the following address: The Subscription Department The National Medical Journal of India All India Institute of Medical Sciences Ansari Nagar New Delhi 110029 The subscription rates of the journal are as follows: One year Indian Overseas Rs 500 $80 Two years Rs 900 $140 Three years Rs 1300 $200 Personal subscriptions paid from personal funds are available at 50% discounted rates. Kumar R. Garvey MA.155: 264–71.354:1153–8. et al. 4 Nandi S. Antibodies reacting with cytoplasm of subthalamic and caudate nuclei neurons in chorea and acute rheumatic fever. Vohra H. Ray P. please add Rs 90 per annum to the total payment and make the request at the time of subscribing. Zabriskie JB. Lancet 1999. Leckman JF. Please send all renewals and new subscriptions along with the payment to the above address. J Exp Med 1976. Arch Gen Psychiatry 2000. Leitman SF. Staib L. . If you wish to receive the Journal by registered post. 3 Peterson BS. Cheques/Demand Draft should be made payable to The National Medical Journal of India. Am J Psychiatry 1998. and attention deficit/hyperactivity disorders. 6 Perlmutter SJ. van de Rijn I.79:528–33. Preliminary findings of antistreptococcal antibody titers and basal ganglia volumes in tic. Abdin ZH. Group A streptococcal sore throat in 23 a periurban population of northern India: A one-year prospective study. obsessive compulsive. Tucker D. Please add Rs 50 for outstation cheques. Scahill L. Zhang H. Bull World Health Organ 2001.144:1094–110. Therapeutic plasma exchange and intravenous immunoglobulin for obsessive–compulsive disorder and tic disorders in childhood. Leonard HL. Ganguly NK. Feldman E. Williams RC Jr.57:364–72.