by CASE: 7 yr old female (fully vaccinated) came to the ED with sore throat of 3 days duration, sent from school for vomiting and having a full body tremor. Vitals stable, afebrile. On examination she was tremulous without any focal neuro deficits, able to follow commands and speaking in full sentences (all while continuing to shake).
Exam positives included: Tremulous throughout examination with distractability (pausing during finger to nose testing) AND erythematous oropharnyx +tonsilar exudates.
Tested Rapid Strep +
Okay, so this kid had strep pharyngitis but what is up with the shakes?
PANDAS
–>Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus Infections
What:National Institute of Mental Health describes it as: OCD and vocal/motor tics that occur following a strep infection OR worsening of tics/OCD follow a strep infection ALONG WITH mood irritability and anxieties
Who: -must have presence of OCD and/or tic disorder
-must first become evident by the age of three and then repeated pre-pubertal -abrupt onset or dramatic symptom exacerbation
-associated with positive throat culture and/or elevated anti-GABHS antibody titers -choreiform movements BUT NOT chorea
Treatment: treat the strep infection, maybe give some steroids? some IVIG? some plasmaphoresis?
-basically the peds community is approaching this as a psych issue (underyling OCD/tics) so starting CBT (cognitive behavorial
therapy) or an SSRI may or may not be the way to go… …while they all figure out if this disease actually exists…
–>Looked at longitudinal and prospective studies with a total of about 200 children (control= children with OCD, test group=children showing PANDAS symptoms)
Bottom Line: no significant evidence that the strep infections are associated with higher rates of neuropsychiatric symptoms, but study sizes were small and they would like a larger study
References:
- https://dontforgetthebubbles.com/schrodingers-pandas/
- https://insights.ovid.com/crossref?an=00006454-900000000-96511
- https://www.nimh.nih.gov/health/publications/pandas/index.shtml
Enjoy your Sunday!
