Published online June 2, 2008
PEDIATRICS Vol. 121 No. 6 June 2008, pp. 1188-1197 (doi:10.1542/10.1542/peds.2007-2657)

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ARTICLE

Streptococcal Infection and Exacerbations of Childhood Tics and Obsessive-Compulsive Symptoms: A Prospective Blinded Cohort Study

Roger Kurlan, MD^a, Dwight Johnson, BS^b, Edward L. Kaplan, MD^b and the Tourette Syndrome Study Group

^a Department of Neurology, University of Rochester School of Medicine, Rochester, New York
^b World Health Organization Streptococcal Reference Laboratory, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota

OBJECTIVE. If pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections is a unique clinical entity, we hypothesized that children meeting diagnostic criteria would have more clinical exacerbations temporally linked to bona fide group A β-hemolytic streptococcus infection than matched control subjects (chronic tic and/or obsessive-compulsive disorder with no known temporal relationship to group A β-hemolytic streptococcus infection).

PATIENTS AND METHODS. Subjects included 40 matched pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections case-control pairs who were prospectively evaluated with intensive laboratory testing for group A β-hemolytic streptococcus and clinical measures for an average of 2 years. Additional testing occurred at the time of any clinical exacerbations or illness. Laboratory personnel were blinded to case or control status and clinical (exacerbation or not) condition. Clinical raters were blinded to the results of laboratory tests.

RESULTS. The cases had a higher clinical exacerbation rate and a higher bona fide group A β-hemolytic streptococcus infection rate than the control group. Only 5 of 64 exacerbations were temporally associated (within 4 weeks) with a group A β-hemolytic streptococcus infection, and all occurred in cases. The number (5.0) was significantly higher than the number that would be expected by chance alone (1.6). Yet, 75% of the clinical exacerbations in cases had no observable temporal relationship to group A β-hemolytic streptococcus infection.

CONCLUSIONS. Patients who fit published criteria for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections seem to represent a subgroup of those with chronic tic disorders and obsessive-compulsive disorder who may be vulnerable to group A β-hemolytic streptococcus infection as a precipitant of neuropsychiatric symptom exacerbations. Group A β-hemolytic streptococcus infection is not the only or even the most common antecedent event associated with exacerbations for these patients. Additional intensive studies are needed to determine whether there is clinical or scientific evidence to support separating out subgroups of tic disorder and/or obsessive-compulsive disorder patients based on specific symptom precipitants.

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Key Words: PANDAS • group A streptococcal infection • pharyngitis • tics • obsessive-compulsive disorder • neuropsychiatric symptoms

Abbreviations: GABHS—group A β-hemolytic streptococcus • PANDAS—pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections • OCD—obsessive-compulsive disorder • DSM-IV—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • ASO—antistreptolysin O • anti-DNase B—antideoxyribonuclease B • CY-BOCS—Children's Yale-Brown Obsessive-Compulsive Scale • YGTSS—Yale Global Tic Severity Scale • ADHD—attention-deficit/hyperactivity disorder • ASQ-P—Conners Abbreviated Symptom Questionnaire-Parent • CDI-SV—Child Depression Inventory-Short Version • MASC—Multidimensional Anxiety Scale for Children • TS—Tourette syndrome

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Accepted Nov 14, 2007.

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