Obsessive-Compulsive Disorder Related to Mycoplasma-Associated Autoimmune Encephalopathy with Basal Ganglia Involvement.

Abstract

[Author Affiliation]Yangsik Kim. 1 Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.Tae-Sung Ko. 2 Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.Mi-Sun Yum. 2 Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.Ah Young Jung. 3 Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.Hyo-Won Kim. 1 Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.Address correspondence to: Hyo-Won Kim, MD, PhD, Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea, E-mail: shingubi@amc.seoul.krTo the Editor:There is an increasing body of literature implicating autoimmune abnormalities in obsessive-compulsive disorder (OCD). In 1980, investigators noted that a subset of children with OCD had experienced a sudden onset of psychiatric symptoms, typically following infection with Group A Streptococcus, and labeled this autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) (Swedo et al, 1998; Murphy et al, 2014). PANDAS is hypothesized to result from postinfectious autoimmunity mediated through cross-reactive antibodies, produced against molecular mimics or epitopes on the Group A Streptococcus cell wall, which resemble host antigens (Murphy and Pichichero 2002).Autoimmune responses associated with the onset and progression of neuropsychiatric disorders such as OCD and Tourette's disorder are not limited to streptococcal infection, and in 2014, diagnostic criteria and recommendations for clinical evaluation of pediatric acute-onset neuropsychiatric syndrome (PANS) were released (Chang et al. 2014). PANS is defined as abrupt-onset OCD or severely restricted food intake with concurrent presence of neuropsychiatric symptoms after either an infectious trigger or an environmental trigger (Swedo et al. 2012). However, there are few reports on autoimmune-related OCD, including PANDAS and PANS, from regions other than North America, and there are particularly few reports from Asia. In this report, we present a 14-year-old Korean girl who presented with an abrupt onset and waxing-and-waning course of obsessive-compulsive symptoms with serological evidence for Mycoplasma pneumoniae and brain involvement, mainly basal ganglia.Case ReportA 14-year-old girl presented to the Department of Psychiatry in January 2013 with obsessions and compulsions including the need for symmetry and orderliness, worries related to harm befalling her and her family, rituals involving herself and parents, and restricted food intake related to OCD symptoms. Emotional lability, irritability, behavioral regression, and deterioration in school performance were also present.The patient was developmentally normal and had no premorbid neuropsychiatric symptoms before December 2009. With respect to family history, the paternal grandmother had OCD. The patient's OCD symptoms, emotional lability, and decreased school performance started in December 2009. Several months before the onset of these symptoms, the patient had had a low-grade fever, cough, and nonexudative pharyngitis with cervical lymphadenopathy. The pathogen was not identified. After 2 weeks of empirical treatment with amoxicillin/clavulanate, the patient's pharyngitis and lymphadenopathy had resolved. OCD symptoms waxed and waned despite cognitive behavioral therapy.The patient developed binocular diplopia in January 2012. At that time, she did not have fever or any other physical or neurological symptoms except for diplopia. Brain magnetic resonance imaging (MRI) showed high-signal-intensity lesions in the right pons, both superior cerebellar peduncles, the right cerebral peduncle, and the midbrain (Fig. …