Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcus

Abstract

To the Editor.In a recent issue of Pediatrics, Gabbay et al1 examined the treatment of PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcus) in the community and at a specialty clinic. The article represents a lot of what is wrong in pediatric psychiatry. The premise was arrogant, and an opportunity for discovering something of clinical significance was wasted. The novel use of antibiotics arose out of observations in the 1980s that some children with obsessive-compulsive disorder (OCD)/Tourette syndrome (TS) had evidence of preexisting streptococcal infection, and these psychiatric manifestations were akin to Syndenham chorea.2 The association has been epidemiologically difficult to prove and remains controversial. Nevertheless, over the last decade, antibiotics have been used to treat these disorders, especially when educated parents demand a trial of antibiotics before allowing their child to be placed on long-time α agonists or neuroleptics. As mentioned in the article, 3 prospective studies that examined the efficacy of antibiotic prophylaxis (used for acute rheumatic fever) in children with OCD/TS plus evidence of previous streptococcal infection have been inconclusive.3–5 The real question is, is antibiotic treatment useful in treating various symptoms of psychiatric dysfunction in the pediatric population, especially OCD/TS? Can parents, the children themselves, or third parties, teachers, and medical staff notice any relief from the maddening compulsions or mood swings during a course of treatment? If this treatment is helpful to a certain subset of children, the next question is, how is it working, and can we define who might benefit? Maybe it is related to streptococcal infection, or maybe there is a completely alternative explanation. Possibly, there is an antiinflammatory effect from the antibiotics, and children without preexisting streptococcal infection improve.6 Maybe the alteration in gut microflora from antibiotics leads to changes in central nervous system function. It is interesting that there is a community of parents who request antibiotic treatment for chronic central nervous system Lyme disease for their psychiatrically symptomatic children.7 It is certainly possible that these “PANDAS parents” or “chronic Lyme parents” are in denial that their children suffer from psychiatric disorders and are unrealistic in insisting that antibiotics be used rather than the “conventional treatment.” However, just possibly, the observations of parents and “community” physicians have merit. Certainly there is curiosity about what did happen clinically to the children who received antibiotics in the community. By narrowly defining what the specialty psychiatrists determine are indications for use of antibiotics, the authors did not even examine what is actually happening that might be helpful for children. They arrogantly concluded that the community doctors were displaying, “unwarranted use of antibiotic treatment for tics/OCD without evidence of laboratory infection.” They missed the point.