8/12/2019 From Our Autumn 2011 Issue

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10 www.autismeye.comAutism |eye I ss ue 3 2011 www.autismeye.com 11Autism |eye I s sue 3 2011

Paediatric Autoimmune Neuropsychiatric DisordersAssociated with Streptococcus(PANDAS) is a recently discoveredcondition in which an infectionleads to obsessive behaviours. Thecommon bug, Streptococcus, isassociated mainly with tonsillitisand sore throats. In some, theinfection triggers antibodies that,while fighting the infection, alsohave an impact on the brain.Classically, there is a clear historyof sudden-onset obsessivebehaviour following a sore throat;remission of obsessions generallyfollows resolution of the infection.

In terms of our children withautistic spectrum disorder (ASD), itis a useful diagnosis to consider.PANDAS can be diagnosedclinically, and there is a clear andreasonably accurate array of labtests to confirm it. Also, it usuallyresponds to antibiotics(azithromycin, penicillin or acephalosporin), and there is someevidence it may respond to milderantimicrobials such as olive leafextract or sage.

The tests can be performed atany GP surgery or hospital, andinclude: ASOT (a strep antibodytest), Anti-DNAse B (anotherantibody test), or a throat swab.

In its classical form, and that isto say its diagnosis, it isuncommon in ASD. A smallpercentage of those withobsessive-compulsive disorder

Medical understanding

A condition associated with the common sore-throatbug Streptococcus can lead to obsessive behaviour.Its worth taking into consideration in children withautism and it can be treated, says Dr Daniel Goyal

What throats can tell us

If there is a sudden onset ofobsessive behaviours and then afairly sudden resolution, you shouldcontact your paediatrician and raisethe possibility of PANDAS If there is marked obsessivebehaviour, then one must considerStreptococcus. Is the throat sore, orred? Are the glands up? There is a difference betweenrepetitive behaviour and obsessivebehaviour. Obsessive is morecomplex, and when interruptedusually causes more distress Other infections are probablyable to cause obsessive issues Generally, improving the immunesystem should be helpful, but it canlead to a flare-up of symptoms.Insist someone looks at the throat/tonsils. A blood test taken duringthe flare-up is useful Antibiotics may be needed to getthe immune response settled down.While this is not ideal, rememberthat herbal remedies are antibioticstoo. Support the gut, and monitorthe results. Contacts, such as otherfamily members, may need to bescreened and/or treated to stop anyre-infection Some suggest Streptococcusmay also be present in other sitessuch as the ear or bowel. If so, anantibody test will be required toidentify it There are other treatmentmethods available, such as atonsillectomy, but these needexpert advice and patientconsideration.

Key issues

Environmental

physician Dr Daniel

Goyal is a member of

the clinical team at

Breakspear Hospital

in Hertfordshire, UK,

where he runs several

environmental

medicine clinics and

two autism clinics

(OCD) behaviour and ASD do fulfilthe criteria for diagnosis (probablyless than 10%). However, PANDASraises some useful questions forASD, and particularly for those withobsessive behaviours.

First, the discovery ofStreptococcus as a cause for amental health condition has beenquite a milestone. A disease thatwould previously have beentreated through psychology orpsychopharmacology, often quitesuccessfully, can now be treatedthrough antibiotics. The immunesystem, it would seem, can havemarked effects on behaviour.

This finding is further reinforcedby a recent study on mice, in

The immune system, it would seem, canhave marked effects on behaviour

which the immune system wasexchanged in mice suffering OCD,with resolution of the OCD.

The experiment was not done topropose exchanging the immunesystem as a treatment modality, butto emphasise that immunomodulationmay well be a good route to explorein, at least, OCD.

ImmunotoxicityThe second question pertains tothe inability of some children to getrid of infections or respondadequately to them. In our patientgroup this is usually down toimmunotoxicity, and this essentiallymeans the immune system isinhibited by an environmental toxin

from performing adequately. Thisusually leads to prolonged andunusual responses to infections.Therefore, it may be that somechildren develop obsessive-typebehaviours or thoughts secondaryto infection, but the behaviour doesnot fully resolve or suddenly improve.

The infection (Streptococcus, forexample) may not resolve as itdoes in a healthier immune system,and hence the sudden onset andsudden remission may not occur

either. Instead, there may be aslow-burn OCD-type issue that mayfluctuate with a fluctuating immunesystem. Our added difficulty is thatoften our children cannotcommunicate the sore throat or,indeed, cannot perceive it as asore throat.

The third issue raised herepertains to the actual mechanismof illness. PANDAS is classed asan autoimmune condition. That is,the immune system overreacts to

an infection, with some issuecausing cross-reactivity. It isalmost an exaggerated immuneresponse. If the immune system isimpaired, such as is present in asub-group of ASD children, thenthe full extent of what is actuallythere (such as Streptococcus) mayonly be realized once the immunesystem starts to recover.

Often, we witness children doingwell apart from the obsessive side,or that when nutrition improves theimmune response obsessions startto flare-up. This is the time toscreen them for Strep-inducedbehaviour problems, or, indeed,other infections such as Clostridia,yeast or HHV-6.