A rare presentation of Pediatric Autoimmune Neuro-psychiatric Disorder Associated with Group A Streptococcal infections (PANDAS)

Abstract

A 9 year old girl presented to us with a history of sudden onset left sided hemiparesis. Neurological examination revealed an upper motor neuron type of left facial nerve palsy, episodes of dystonia involving left upper and lower limbs and an extensor plantar response on the left side. The girl showed several adventitious movements such as choreiform movements involving the whole of the left upper extremity and the distal left lower extremity. Additionally, facial tics causing a grimacing facies were seen off and on. Interestingly, a mitral regurgitation murmur was discovered on routine clinical examinations and confirmed by echocardiography. With this background and a past history of acute tonsillitis 3 years back, we got two Anti-Streptolysin O (ASO) titres done 3 weeks apart which were markedly elevated and showed a rising titre; 406 IU/L and 815 IU/L respectively. The girl was started on oral prednisolone ,oral penicillin and oral haloperidol and she responded dramatically within 5 days. Stroke syndrome, as a cause of the acute hemiparesis, was ruled out by neuroimaging (MR-angiography). The clinical profile of our case fulfilled all the diagnostic criteria for Pediatric Autoimmune Neuro Psychiatric Disorder Associated with Streptococcal infections (PANDAS). But here, we are reporting not just another case of PANDAS, but one with a unique difference: the association of complete hemiparesis with PANDAS.