HEALTH JOURNAL
DECEMBER 13, 2011
Does Strep Throat Trigger Serious Ills?
Researchers Link Common Ailment With Rare Disorders, Such as Behavioral Issues, Tics
· By MELINDA BECK
Millions of U.S. children get strep throat every year, and in the vast majority of cases, symptoms clear up quickly. In a small number of cases, however, the outcome may be more worrisome.
The average grade-school kid gets two to three strep infections per year, and a growing body of research suggests that strep can bring on sudden OCD in some kids, as well as ADHD-like symptoms and depression. Melinda Beck has details on Lunch Break.
Research is just beginning into the condition known as Pandas (for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus). That's when the same Group A streptococcus bacteria seem to trigger an autoimmune reaction that brings a sudden onset of obsessive-compulsive disorder (OCD), tics and other neurological changes, including anxiety, irritability, hyperactivity, anorexia and urinary problems.
"Parents have used the word 'possessed,' " says Susan Swedo, chief of pediatrics and developmental neuroscience at the National Institute of Mental Health who first made the connection to strep in the mid-1990s. "Their sweet, wonderful child turns into a monster seemingly overnight."
In some cases, the neurological symptoms resolve with antibiotics, although they often return and worsen if the child is exposed to strep again. But the diagnosis is controversial and experts are divided over when to test children with sudden OCD for strep, and whether to treat them with antibiotics and for how long.
Typical strep symptoms include a sore throat and swollen glands.
"There's definitely something going on with these kids, but right now, you could walk into one doctor's office and they could be a believer and move forward with treatments and some would not," says Manhattan child psychiatrist Andrew Gilbert, who frequently treats children with OCD.
About 1% of U.S. children have OCD, and as many as 20% have transient tic disorders. But nobody knows how many of those may be strep-related—or whether some cases of adult OCD might have been triggered years ago by strep. Scientists think Pandas children have a genetic predisposition to mount an unusual immune response when exposed to the strep bacteria. Many have a family history of rheumatic fever, a strep complication rarely seen in the U.S. these days in which antibodies to strep mistakenly attack heart valves. In a related disorder called Sydenham's chorea, strep antibodies attack the part of the brain that controls movement, causing jerking, stumbling, weakness and difficulty writing. Some experts think the Pandas cases may be a version of Sydenham's.
University of Oklahoma immunologist Madeleine Cunningham has shown in lab tests that strep antibodies bind to brain cells and cause them to release excess dopamine, which has been linked to tics and OCD symptoms. Having done blood analyses on nearly 1,000 children with Pandas, she also hopes to develop a test for such antibodies that could diagnose Pandas definitively.
For now, doctors diagnose Pandas only if children have episodes of OCD, tics or other neurological issues near the time of a strep infection. But some families recognize it only in retrospect or by accident. Susan Dailey of Davidson, N.C., says that at age 3, her daughter suddenly started washing her hands until they bled, refused to eat and acted terrified—but the symptoms vanished within two weeks after she went on antibiotics for a double ear-infection. After more bouts, she was diagnosed with Pandas at age 7.
Strep vs. a Cold
About 80% of respiratory illnesses are due to viruses and don't need treatment. How to tell the difference:
•Strep
Symptoms: Sore throat, swollen lymph nodes in neck, painful swallowing, fever, headache, nausea
Affects: Mostly kids 3 to 15
Treatment: Penicillin or other antibiotics
Complications: Throat abscess, kidney inflammation, rheumatic fever, heart disease
•Cold
Symptoms: Congestion, runny nose, eye discharge, cough, hoarseness
Affects: All ages
Treatment: Rest, fluids, time
Complications: Some strains can progress to sinus or ear infections, inflamed airways, bronchitis or pneumonia
The Boston-based International OCD Foundation (IOCDF) recommends that any child who has such sudden OCD-like symptoms be tested for strep or other active infections. "Children don't go crazy overnight," says Mrs. Dailey, who is on the IOCDF board. When a patient comes in with such symptoms, "the pediatrician needs to realize that this may not be a psychiatric issue. It is probably related to illness—start by testing for strep or other active infections." If the throat culture is negative, the foundation advises doctors to test for evidence of past strep that could lay the groundwork for other treatments.
The American Academy of Pediatrics is more cautious. It recommends that pediatricians test for strep only when a child has typical strep symptoms, such as a sore throat, and prescribe antibiotics for an active infection. "Every child with strep throat should be treated, but without more evidence, we don't want parents of children with OCD or tic disorders to think that their child can be cured by antibiotics," says Mary Anne Jackson, a member of the academy's committee on infectious diseases.
And until there are larger studies with antibotics, the group says children with Pandas should get standard care for OCD and tics, typically antidepressants and cognitive-behavioral therapy. "Very commonly, desperate parents would rather have an antibiotic than go that route," Dr. Jackson says.
Some parents are incensed that doctors are willing to prescribe psychotropic drugs to their young children but not 10 days of penicillin. And some Pandas specialists aren't waiting for more studies. "I've been working in psychiatry for 20 years and I've never seen psychotropic medications turn a child around as quickly as I've seen antibiotics turn a Pandas child around," says Tanya Murphy, director of the Rothman Center for Pediatric Neuropsychiatry at the University of South Florida. She and some other specialists also sometimes put severely affected children on antibiotics to prevent new cases of strep from worsening their OCD symptoms.
The IOCDF plans to sponsor a study at the University of South Florida and Harvard next year treating Pandas children with antibiotics whether they have an active infection or not.
And the NIMH is testing whether giving Pandas patients injections of plasma from healthy donors, intravenous immunoglobulin (IVIG), can reset their immune systems and for how long.
Many other questions remain unanswered—but experts agree that parents should be on the lookout for signs of strep, and get it investigated as soon as possible.
Write to Melinda Beck at HealthJournal@wsj.com
