ANTI-BRAIN AUTOANTIBODIES IN PEDIATRIC AUTOIMMUNE NEUROLOGICAL DISORDERS ASSOCIATED WITH STREPTOCOCCAL INFECTIONS (PANDAS)

Laboratory and clinical features and the impact of anti-Strep antibodies and tonsillectomy

 

Principal Investigator:

 

Eric Hollander, M.D.

Director, Spectrum Neuroscience and Treatment Institute

901 5th Avenue, New York, NY

 

Co-Investigators:

 

Stefano Pallanti, MD, PhD

Associate Professor of Psychiatry

University of Florence

 

Max April, MD

Clinical Associate Professor

NYU School of Medicine

 

Stanley J. Naides, MD

Medical Director, Immunology Research and Development

Quest Diagnostics Nichols Institute

 

Funded by:

Quest Diagnostics Nichols Institute

 

Researcher’s Contact Person:

 

Casara Jean Ferretti, M.S.

Operations Manager, Spectrum Neuroscience and Treatment Institute

901 5th Avenue, New York, NY

Ph: 646-351-0213

cferretti@spectrumneuroscience.org

 

 

Synopsis

 

 

Study Title

ANTI-BRAIN AUTOANTIBODIES IN PEDIATRIC AUTOIMMUNE NEUROLOGICAL DISORDERS ASSOCIATED WITH STREPTOCOCCAL INFECTIONS (PANDAS)

 

Objectives

The primary objective of the clinical research study is to examine the autoimmune etiology of PANDAS by testing patients for recent or concurrent infection with Group A β-hemolytic Streptococci (GABHS), performing standard blood work, anti-neuronal autoantibody profile, immunophenotyping, measurement of cytokines, genetic sampling in patients with presumptive PANDAS and 1) compare and contrast the autoantibody profile in those who test positive for GABHS with those who are negative for GABHS; 2) obtain tonsillectomy/adenoidectomy history and contrast course for and compare those with and without tonsillectomy; and 3) compare pre- and post- treatment in those who have PANDAS to evaluate the impact of treatment  in children with PANDAS. This study will contribute to better understanding of PANDAS diagnosis, symptoms, the relationship between antibrain antibodies and anti-Strep antibodies, and impact of treatment.

 

Design and Outcomes

Initially 150 patients will be enrolled who meet criteria, and are suspected, of having a PANDAS diagnosis.  They will be tested for infection with GABHS and blood will be drawn for clinical laboratory testing. Those patients who have anti-Streptococcal A antibodies will be referred back to their clinicians for treatment. After 3 months, the study subjects will repeat the laboratory and clinical evaluation for PANDAS.  For patients already being treated for a PANDAS diagnosis, only the initial clinical laboratory testing will be completed.

 

Interventions and Duration

The subjects enrolled will be evaluated for clinical diagnosis of PANDAS, co-morbidities, previous medications taken, history of tonsillectomy and medical history. Peripheral venous blood will be drawn for complete blood work and tests for infection and autoimmunity. Throat swabs will be collected for detection of GABHS infection for those positive for GABHS. Those initially diagnosed with, and treated for, PANDAS will return after three months for repeat peripheral blood testing to evaluate the effectiveness of therapy and presence of anti-brain autoantibodies.

 

Sample Size and Population

150 male and female subjects aged 3 to 21 years old will be enrolled into the study.

Study Objectives

 

Primary Objectives:

PANDAS are result of pathological autoimmune reaction directed towards brain antigens arising from infection of children with GABHS. The primary objective is to compare the children:

  1. who are anti-Strep antibody (Ab) positive [ASO-Ab (+) and DNAseB-Ab(+)] to those who are anti-Strep Ab negative [ASO-Ab( –) and DNAseB-Ab(-)];
  2. who have had tonsillectomy/adenoidectomy to those without tonsillectomy/adenoidectomy;
  3. For those who are initially diagnosed and treated, Anti-Strep Ab positive subjects before and after treatment by their clinicians.

 

These comparisons will reveal information about pathological anti-brain autoimmunity as a result Streptococcal infection in PANDAS before and after appropriate clinical treatment.

 

Secondary Objectives:

The secondary objectives are to develop improved means of PANDAS diagnosis and treatment, to collect data about the autoimmune dysfunction and types of anti-neuronal antibodies, and to identify useful biological disease markers in peripheral blood.

 

Background

 

An increasing body of evidence indicates that an immune basis might underlie a number of pediatric neuropsychiatric disorders. There is a well-documented association between infection with Group A β-hemolytic Streptococci (GABHS) and the childhood neuropsychiatric disorder Sydenham chorea which is a form of rheumatic fever. There is a subgroup of children with GABHS infection, sudden onset of tics and/or compulsive behaviors without chorea which is identified by the acronym “Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection” (PANDAS) (Swedo SE et al, 1998). The same symptoms with abrupt onset, OCD and/or tics may appear after other infections with viruses and bacteria such as Influenza, Varicella, Mycoplasma pneumonia, and Borrelia burgdoferi which also causes Lyme disease (Rhee H and Cameron DJ, 2012), and are distinguished by the term “Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders (PITANDS)”.  More recently, an expanded clinical entity is identified, “Pediatric Autoimmune Neuropsychiatric Disorders (PANS”) which occur suddenly without an obvious infection or immune etiology and include the PANDAS. This is why it is important to test for infection with GABHS in order to distinguish between these subtypes which will have implications for therapy. Recently adult-onset, dystonic and myoclonic variant of PANDAS have been described.

 

The most frequently observed immunologic abnormality in patients with Sydenham chorea and PANDAS is presence of anti-brain antibodies in the serum and/or cerebrospinal fluid. It is believed that in Sydenham chorea and PANDAS the pathological immune response is due to cross-reactivity between the Group A Streptococcal antigens and the body’s own brain antigens, termed “pseudo-autoimmune” response. In Sydenham chorea the immune response is triggered to the basal ganglia whereas some cross-reactive anti-brain antibodies instead cause OCD, tics and the neuropsychiatric symptoms of PANDAS (Trifilletti RR and Packard AM, 1999; Fusco FR et al, 2010). The presence of different anti-brain antibodies has been documented in PANS subjects using various techniques such as immunofluorescence (Pavone P et al, 2004; Morshed SA et al, 2001), Western blot and ELISA (Gause C et al., 2009; Morshed SA et al, 2001) but their exact specificity and presence during the disease progression is not well characterized. Therefore, testing for the presence of anti-brain autoantibodies in patients with PANDAS before and after treatment, and identifying their specificity is important. The etiological role of autoimmunity is supported by evidence that both Sydenham chorea and PANDAS have high proportion of D8/17 antibody positive peripheral B cells which is a trait marker of susceptibility to rheumatic fever (Swedo SE et al, 1997). The clonal expansion of D8/17+ peripheral lymphocytes suggests presence of immune dysfunction and is a useful marker in patients with PANDAS.

 

Recently one study reports fewer regulatory T cells in a combined group of children with Tourette syndrome and/or OCD compared to controls, suggesting impaired immune tolerance in these patients (Kaikowa I et al, 2007; Martino D et al, 2009). Another investigative approach has focused on the possible role of cytokines, which are modulators of the immune system. These studies have found increase levels of serum Tumor Necrosis Factor (TNF)-alpha, and Interleukin-12 (IL-12) in a combined group of children with Tourette syndrome and/or OCD compared to controls (Leckman JF et al, 2005).

 

Evidence for an immune-mediated basis in PANDAS is given by the good response in these patients by treatment with intravenous immunoglobulin (IvIg) and plasma exchange (Perlmutter S et al, 1999). IvIg is administered as immunomodulatory therapy in some autoimmune diseases. The current understanding is that IvIg acts through several different mechanisms, depending on the nature of the disease, one of them being restoring the perturbed natural auto-antibody network interactions (Vani J et al, 2008). There is sufficient research on the beneficial properties of IvIg in OCD and PANDAS, including dose therapy and effects on the immune system.

 

Several recent studies using quantitative magnetic resonance imaging (MRI) have reported decreases and/or asymmetries in the volume of the basal ganglia in patients with Tourette syndrome/OCD. The reports of imaging in patients with PANDAS are limited and an increase in the basal ganglia has been reported (Elia J et al, 2005). These volumetric changes are very similar to the ones observed in Sydenham chorea and indicate that the pathological processes in PANDAS affect the basal ganglia.

 

Further studies are necessary to understand the changes in autoimmunity and effectiveness of treatment in children with PANDAS. Dr. Eric Hollander, an expert in PANDAS diagnosis and treatment, will be conducting a research study in collaboration with Dr. Stanley Naides, Dr. Max April, New York University, and Quest Diagnostics to learn more about PANDAS diagnosis, symptoms and treatment options. To date there is no report in the medical and scientific literature about a detailed study of all immune parameters in peripheral blood from children with PANDAS which will be tested in the present study (lymphocyte immunophenotyping, cytokines, autoantibodies to neuronal antigens, PAX gene), and how these immune parameters are influenced by treatment.

 

At present the diagnosis of PANDAS is mainly clinical (Hollander E et al, 2009). It is based on the abrupt presentation of OCD and/or tics (according to DSM-IV TR criteria) immediately following GABHS infection. The onset is usually before puberty and the physical examination must rule out Sydenham chorea and other forms of rheumatic fever. There may be association with other neuropsychiatric symptoms such as ADHD, motoric hyperactivity, anxiety, sensory abnormalities, concentration difficulties, irritability, and emotional labiality. These symptoms are accompanied by positive anti-GABHS antibodies and Streptococcal culture.

 

Study Design

This is an observational clinical study in which one hundred and fifty subject male and female subjects aged 3-21 years old suspected of having PANDAS will be enrolled. They will present to the Spectrum Neuroscience and Treatment Institute for explanation of the study, obtaining of signed consent/assent forms, medical history, information about medications taken, completion of questionnaires and consent to collect their clinical history from previous treating physicians. The study subjects will then go to a Quest Diagnostics laboratory to have blood drawn and throat swabs collected. The patients who are positive for anti-Strep antibodies will be referred back to their clinicians for appropriate treatment. The subjects who have tested positive for Anti-Strep antibodies and who were treated by their clinician will return to Spectrum again after 3 months to complete additional questionnaires, and go to a Quest Diagnostics lab to repeat the clinical laboratory blood work. This 3-month time period is chosen because it sufficient for treatment of the Streptococcal infection and PANDAS. Serum and plasma will be archived upon consent for possible subsequent testing as relevant analyses are identified. The patients’ clinicians will send information about the tonsillectomy/adenoidectomy and clinical history to the Spectrum Neuroscience and Treatment Institute where the collection, analysis and interpretation of all data will be carried out. Patients who are already diagnosed with PANDAS and have received treatment in the past will only complete the initial visit and a single blood draw and throat swabs collection.

 

Selection and Enrollment of study subjects:

    

       Inclusion Criteria:

  1. Male or female patients aged 3-21 years old
  2. Suspected of, or already diagnosed with, PANDAS

 

       Exclusion Criteria:

  1. Inability or unwillingness of subject or parent/caregiver to give written informed consent.
  2. Inability to tolerate venipuncture.

 

       Study Tasks: 

  1. Full blood work and throat cultures for Streptococcal infection on those children who have, or who are suspected of having, PANDAS
  2. History of tonsillectomy/adenoidectomy and of pre-and post-tonsillectomy strep tests
  3. History of treatment
  4. Clinical History of OCD, PANDAS, tics, ADHD, disruptive behavior
  5. Complete Medical History
  6. Completion of optional questionnaires related to diagnosis, including the following

–          Spence Children’s Anxiety Scale

–          Spence Children’s Anxiety Scale (Parent Report)

–          Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) Symptom Checklist and Severity Rating Scale

–          Yale Global Tic Severity Scale

  1. Repeated full blood work and throat cultures on those children who are initially diagnosed with PANDAS through the study blood work, test positive for anti-Strep antibodies and who have received appropriate treatment by their clinician (completed after three months of treatment).
  2. Data entry and analysis of all information collected including blood test results, questionnaire results, patient medical history and medications

 

Clinical and Laboratory Evaluations

The initial evaluation will include clinical history, questionnaires and clinical lab testing. Patients (n = 150) with, or suspected of having, a PANDAS diagnosis will go to Quest Diagnostics for blood draw and throat culture that will test for:

–          Anti-Streptococcal group A antibodies (ASO, DNAse B)

–          CBC and differential, including eosinophil count

–          Immunophenotyping by flow cytometry: CD3, CD4, CD8, CD19, CD16/56, CD3/CD4/CD45RA, CD3/CD8/CD45RA, CD3/CD4/CD45RO, CD38

–          Throat swab, Streptococcal group A culture

–          Throat swab, Streptococcal group A DNA

–          C3, C4, CH50, AH50, mannose binding protein

–          Cytokines: Interleukin 2, Interleukin 4, Interleukin 5, Interleukin 6, Interleukin 10, Interleukin 12p20, Interferon gamma, Tumor Necrosis Factor 

–          Autoantibody levels: Ri, Hu, Yo, Aquaporin 4, NMDR1, AMPAR, mGlut, GABA, CV2, Amphiphysin, Ma2/Ta

–          Paxgene DNA and RNA

–          Peripheral blood mononuclear cells will be isolated from whole blood supplemented with EDTA and cryostored

–          Serum and plasma will be archived for possible subsequent testing.

 

Specimens will be collected at initial evaluation. For patients who are initially diagnosed and who have received three months of treatment for their PANDAS diagnosis from their treating clinician will complete a second set of questionnaires and blood work/throat swabs at the completion of 3 months of therapy. The specimens will be received, processed and stored in the Clinical Correlations Department or the Research & Development Immunology Group. The results of the validated testing will be reported to the Researcher under Standard Operational Procedures. The results of testing by the Research & Development group will be reported to the Researcher by summary report.

 

Clinical and Medical History will provide the following data:

–          Demographics (age, gender, ethnicity)

–          Diagnosis, including symptom spectrum and evaluation instrument assessments

–          Co-morbidities, Medication and surgical history

–          Time since onset of PANDAS symptoms

 

Informed Consent

Subjects will include those diagnosed with, or suspected of having, PANDAS and a parent, caregiver, or guardian identified by the subject to provide the clinical team with information about the subject and his/her diagnosis. Children aged 7 to 12 will complete an assent form.  Children aged 12 to 18 with capacity to consent will sign the consent form with their Parents/Caregivers/Guardians co-signature; and those aged 18 to 21 will sign a consent independently and will not require a parent co-signature. Parents/caregivers/guardians will sign a separate consent that lists them as an informant for the study. As an informant they will complete assessments, via questionnaire or interview with a clinician, that discuss their child’s current and past behavior, current and past symptoms and diagnostic history including the following: medical history/demographic, concomitant medications for their child, and clinical assessments for PANDAS.

 

Medical History will be obtained from the subjects at the initial visit at The Spectrum Neuroscience and Treatment Institute (SNTI) and will also be collected from the treating physicians.

 

Treatment History and information about concomitant treatments will be obtained from the patients at the initial visit at SNTI and will also be collected from the treating physicians.

 

Clinical Assessments will be completed by a member of the research team at the beginning of the study and at the specified time points in the following table, and may include questionnaires about OCD, PANDAS, ADHD, tics, and disruptive behavior.

 

Safety Measures, Risks and Benefits

This is an observational study and no treatment will be provided as a part of this study.  Potential risks include the following:

  • Blood Draw: Risks of a blood draw include pain or bruise at the site of venipuncture, bleeding, swelling, itching and slight inflammation.  In rare cases it may result in an infection.
  • Loss of Confidentiality: All possible steps are taken to protect your information and confidentiality.  Information is stored in secure cabinets or computers to which only authorized personnel have access. All information will be de-identified and will only be linked via a study identifier.  However, there is a risk of loss of confidentiality if these safety measures are breached.
  • Patients may feel uncomfortable discussing personal or sensitive information that is related to questionnaires or interviews.  All efforts will be made to make patients comfortable.

 

Statistical Considerations:

 

The different groups will be compared using regression analyses and analyses of variance and statistical software program.

 

      

 

Schedule of Evaluations

 

Evaluation

Screening/Entry

 

1 mo.

2

mo.

3 mo.

Second Visit

Informed Consent

X

 

 

 

 

I/E Criteria

X

 

 

 

 

Medical and Treatment History

X

 

 

 

X

Tonsillectomy History

X

 

 

 

X

Vital Signs

X

 

 

 

X

Labs at Quest (Blood and Throat Swabs)

X

 

 

 

X

Throat Cultures

X

 

 

 

 

Questionnaires

X

 

 

 

X

Adverse events

X

 

 

 

X

 

 

 

References

1. Swedo, S.E., Leonard, H.L., Garvey, M, Mittelman, B, Allen A.J., Perlmutter, S., Lougee, L, Dow, S, Zamkoff, J, Dubbert, B.K. Pediatric Autoimmune Neuropsychaitric Disorders Associated with Streptococcal Infections: Clinical Description of the First 50 Cases. Am. J. Psychiatry, 1998, 155, 264-271.

2. Rhee S and Cameron DJ. Lyme disease and pediatric autoimmune neurological disorders associated with streptococcal infections: an overview. Int. J. Gen. Med., 5, 163-174.

3. Trifiletti RR and Packard AM. Immune mechanisms in pediatric neuropsychiatric disorders. Tourette’s syndrome, OCD, and PANDAS. Child Adolesc Psychiatr. Clin N. Amer, 1999, 8(4), 767-775.

4. Fusco FRPompa ABernardi GOttaviani FGiampà CLaurenti DMorello MBernardini SNuccetelli MSabatini UPaolucci S. A case of PANDAS treated with tetrabenazine and tonsillectomy. J. Child Neurol., 2010, 25(5), 614-615.

5. Pavone PBianchini RParano EIncorpora GRizzo RMazzone LTrifiletti RR. Anti-brain antibodies in PANDAS versus uncomplicated streptococcal infection. Pediatr. Neurol, 2004, 30(2), 107-110.

6. Morshed SA, Parveen S, Leckman JF, Mercadante MT et al. Antibodies against Neural, Nuclear, Cytoskeletal, and Streptococcal Epitopes in Children and Adults with Tourette’s Syndrome, Sydenham’s Chorea, and Autoimmune Disorders. Biol. Psychiatry, 2001, 50, 566-577.

7. Gause CMorris CVernekar SPardo-Villamizar CGrados MASinger HS. Antineuronal antibodies in OCD: comparisons in children with OCD-only, OCD+chronic tics and OCD+PANDAS. J. Neuroimmunol, 2009, 214(1-2), 118-124.

8. Swedo, S.E., Leonard, H.E., Mittleman, B.B, Allen, A.J., Rapoport, J.L., Dow, S.P., Kanter, M.E., Chapman, F. and Zabriskie, J. Identification of Children with Pediatric Autoimmune Disorder Associated with Streptococcal Infections by a Marker Associated with Rheumatic Fever. Am. J. Psychiatry, 1997, 154, 110-112.

9. Kawikova ILeckman JFKronig HKatsovich LBessen DEGhebremichael MBothwell AL. Decreased numbers of regulatory T cells suggest impaired immune tolerance in children with Tourette syndrome: a preliminary study. Biol. Psychiatry, 2007, 61(3), 273-278.

9. Martino DDale RCGilbert DLGiovannoni GLeckman JF. Immunopathogenic mechanisms in Tourette Syndrome: A critical review. Mov Disord, 2009, 24(9), 1267-1279.

10. Leckman JFKatsovich LKawikova ILin HZhang HKrönig HMorshed SParveen SGrantz HLombroso PJKing RA. Increased serum levels of interleukin-12 and tumor necrosis factor-alpha in Tourette’s syndrome. Biol Psychiatry, 2005, 57(6), 667-673.

11. Perlmutter, S., Leitman, S.F., Garvey, M.A., Hamburger, S., Feldman, E., Leonard, H.L. Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood. Lancet, 1999, 354, 1153-1158.

12. Vani JElluru SNegi VSLacroix-Desmazes SKazatchkine MDBayary JKaveri SV. Role of natural antibodies in immune homeostasis: Ivig perspective. Autoimmune Rev, 2008, 7(6), 440-444.

13. Elia JDell MLFriedman DFZimmerman RABalamuth NAhmed AAPati S. PANDAS with catatonia: a case report. Therapeutic response to lorazepam and plasmapheresis. J. Am Acad Child Adolesc Psychiatry. 2005, 44(11), 1145-1150.

14. Murphy, M.L. and Pichichero, M.E. Prospective Identification and Treatment of Children with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcal Infection (PANDAS). Arch. Pediatr. Adolesc. Med, 2002, 156, 356-361.

15. Murphy, T.K., Storch, E.A., Lewin, A.B., Edge, P.J., Goodman, W.K. Clinical Factors Associated with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. J. Pediatr., 2012, 160-314-319.

16. Snider, L.A., Lougee, L., Slattery, M., Grant, P. and Swedo, S.E. Antibiotic Prophylaxis with Azithromycin or Penicillin for Childhood-Onset Neuropsychiatric Disorders. Biol. Psychiatry, 2005, 57, 788-792.

17. Hollander EKim SBraun ASimeon DZohar J. Cross-cutting issues and future directions for the OCD spectrum. Psychiatry Res., 2009, 170,(1), 3-6.

 

ANTI-BRAIN AUTOANTIBODIES IN PEDIATRIC AUTOIMMUNE NEUROLOGICAL DISORDERS ASSOCIATED WITH STREPTOCOCCAL INFECTIONS (PANDAS)

Laboratory and clinical features and the impact of anti-Strep antibodies and tonsillectomy

 

Principal Investigator:

 

Eric Hollander, M.D.

Director, Spectrum Neuroscience and Treatment Institute

901 5th Avenue, New York, NY

 

Co-Investigators:

 

Stefano Pallanti, MD, PhD

Associate Professor of Psychiatry

University of Florence

 

Max April, MD

Clinical Associate Professor

NYU School of Medicine

 

Stanley J. Naides, MD

Medical Director, Immunology Research and Development

Quest Diagnostics Nichols Institute

 

Funded by:

Quest Diagnostics Nichols Institute

 

Researcher’s Contact Person:

 

Casara Jean Ferretti, M.S.

Operations Manager, Spectrum Neuroscience and Treatment Institute

901 5th Avenue, New York, NY

Ph: 646-351-0213

cferretti@spectrumneuroscience.org

 

 

Synopsis

 

 

Study Title

ANTI-BRAIN AUTOANTIBODIES IN PEDIATRIC AUTOIMMUNE NEUROLOGICAL DISORDERS ASSOCIATED WITH STREPTOCOCCAL INFECTIONS (PANDAS)

 

Objectives

The primary objective of the clinical research study is to examine the autoimmune etiology of PANDAS by testing patients for recent or concurrent infection with Group A β-hemolytic Streptococci (GABHS), performing standard blood work, anti-neuronal autoantibody profile, immunophenotyping, measurement of cytokines, genetic sampling in patients with presumptive PANDAS and 1) compare and contrast the autoantibody profile in those who test positive for GABHS with those who are negative for GABHS; 2) obtain tonsillectomy/adenoidectomy history and contrast course for and compare those with and without tonsillectomy; and 3) compare pre- and post- treatment in those who have PANDAS to evaluate the impact of treatment  in children with PANDAS. This study will contribute to better understanding of PANDAS diagnosis, symptoms, the relationship between antibrain antibodies and anti-Strep antibodies, and impact of treatment.

 

Design and Outcomes

Initially 150 patients will be enrolled who meet criteria, and are suspected, of having a PANDAS diagnosis.  They will be tested for infection with GABHS and blood will be drawn for clinical laboratory testing. Those patients who have anti-Streptococcal A antibodies will be referred back to their clinicians for treatment. After 3 months, the study subjects will repeat the laboratory and clinical evaluation for PANDAS.  For patients already being treated for a PANDAS diagnosis, only the initial clinical laboratory testing will be completed.

 

Interventions and Duration

The subjects enrolled will be evaluated for clinical diagnosis of PANDAS, co-morbidities, previous medications taken, history of tonsillectomy and medical history. Peripheral venous blood will be drawn for complete blood work and tests for infection and autoimmunity. Throat swabs will be collected for detection of GABHS infection for those positive for GABHS. Those initially diagnosed with, and treated for, PANDAS will return after three months for repeat peripheral blood testing to evaluate the effectiveness of therapy and presence of anti-brain autoantibodies.

 

Sample Size and Population

150 male and female subjects aged 3 to 21 years old will be enrolled into the study.

Study Objectives

 

Primary Objectives:

PANDAS are result of pathological autoimmune reaction directed towards brain antigens arising from infection of children with GABHS. The primary objective is to compare the children:

  1. who are anti-Strep antibody (Ab) positive [ASO-Ab (+) and DNAseB-Ab(+)] to those who are anti-Strep Ab negative [ASO-Ab( –) and DNAseB-Ab(-)];
  2. who have had tonsillectomy/adenoidectomy to those without tonsillectomy/adenoidectomy;
  3. For those who are initially diagnosed and treated, Anti-Strep Ab positive subjects before and after treatment by their clinicians.

 

These comparisons will reveal information about pathological anti-brain autoimmunity as a result Streptococcal infection in PANDAS before and after appropriate clinical treatment.

 

Secondary Objectives:

The secondary objectives are to develop improved means of PANDAS diagnosis and treatment, to collect data about the autoimmune dysfunction and types of anti-neuronal antibodies, and to identify useful biological disease markers in peripheral blood.

 

Background

 

An increasing body of evidence indicates that an immune basis might underlie a number of pediatric neuropsychiatric disorders. There is a well-documented association between infection with Group A β-hemolytic Streptococci (GABHS) and the childhood neuropsychiatric disorder Sydenham chorea which is a form of rheumatic fever. There is a subgroup of children with GABHS infection, sudden onset of tics and/or compulsive behaviors without chorea which is identified by the acronym “Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection” (PANDAS) (Swedo SE et al, 1998). The same symptoms with abrupt onset, OCD and/or tics may appear after other infections with viruses and bacteria such as Influenza, Varicella, Mycoplasma pneumonia, and Borrelia burgdoferi which also causes Lyme disease (Rhee H and Cameron DJ, 2012), and are distinguished by the term “Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders (PITANDS)”.  More recently, an expanded clinical entity is identified, “Pediatric Autoimmune Neuropsychiatric Disorders (PANS”) which occur suddenly without an obvious infection or immune etiology and include the PANDAS. This is why it is important to test for infection with GABHS in order to distinguish between these subtypes which will have implications for therapy. Recently adult-onset, dystonic and myoclonic variant of PANDAS have been described.

 

The most frequently observed immunologic abnormality in patients with Sydenham chorea and PANDAS is presence of anti-brain antibodies in the serum and/or cerebrospinal fluid. It is believed that in Sydenham chorea and PANDAS the pathological immune response is due to cross-reactivity between the Group A Streptococcal antigens and the body’s own brain antigens, termed “pseudo-autoimmune” response. In Sydenham chorea the immune response is triggered to the basal ganglia whereas some cross-reactive anti-brain antibodies instead cause OCD, tics and the neuropsychiatric symptoms of PANDAS (Trifilletti RR and Packard AM, 1999; Fusco FR et al, 2010). The presence of different anti-brain antibodies has been documented in PANS subjects using various techniques such as immunofluorescence (Pavone P et al, 2004; Morshed SA et al, 2001), Western blot and ELISA (Gause C et al., 2009; Morshed SA et al, 2001) but their exact specificity and presence during the disease progression is not well characterized. Therefore, testing for the presence of anti-brain autoantibodies in patients with PANDAS before and after treatment, and identifying their specificity is important. The etiological role of autoimmunity is supported by evidence that both Sydenham chorea and PANDAS have high proportion of D8/17 antibody positive peripheral B cells which is a trait marker of susceptibility to rheumatic fever (Swedo SE et al, 1997). The clonal expansion of D8/17+ peripheral lymphocytes suggests presence of immune dysfunction and is a useful marker in patients with PANDAS.

 

Recently one study reports fewer regulatory T cells in a combined group of children with Tourette syndrome and/or OCD compared to controls, suggesting impaired immune tolerance in these patients (Kaikowa I et al, 2007; Martino D et al, 2009). Another investigative approach has focused on the possible role of cytokines, which are modulators of the immune system. These studies have found increase levels of serum Tumor Necrosis Factor (TNF)-alpha, and Interleukin-12 (IL-12) in a combined group of children with Tourette syndrome and/or OCD compared to controls (Leckman JF et al, 2005).

 

Evidence for an immune-mediated basis in PANDAS is given by the good response in these patients by treatment with intravenous immunoglobulin (IvIg) and plasma exchange (Perlmutter S et al, 1999). IvIg is administered as immunomodulatory therapy in some autoimmune diseases. The current understanding is that IvIg acts through several different mechanisms, depending on the nature of the disease, one of them being restoring the perturbed natural auto-antibody network interactions (Vani J et al, 2008). There is sufficient research on the beneficial properties of IvIg in OCD and PANDAS, including dose therapy and effects on the immune system.

 

Several recent studies using quantitative magnetic resonance imaging (MRI) have reported decreases and/or asymmetries in the volume of the basal ganglia in patients with Tourette syndrome/OCD. The reports of imaging in patients with PANDAS are limited and an increase in the basal ganglia has been reported (Elia J et al, 2005). These volumetric changes are very similar to the ones observed in Sydenham chorea and indicate that the pathological processes in PANDAS affect the basal ganglia.

 

Further studies are necessary to understand the changes in autoimmunity and effectiveness of treatment in children with PANDAS. Dr. Eric Hollander, an expert in PANDAS diagnosis and treatment, will be conducting a research study in collaboration with Dr. Stanley Naides, Dr. Max April, New York University, and Quest Diagnostics to learn more about PANDAS diagnosis, symptoms and treatment options. To date there is no report in the medical and scientific literature about a detailed study of all immune parameters in peripheral blood from children with PANDAS which will be tested in the present study (lymphocyte immunophenotyping, cytokines, autoantibodies to neuronal antigens, PAX gene), and how these immune parameters are influenced by treatment.

 

At present the diagnosis of PANDAS is mainly clinical (Hollander E et al, 2009). It is based on the abrupt presentation of OCD and/or tics (according to DSM-IV TR criteria) immediately following GABHS infection. The onset is usually before puberty and the physical examination must rule out Sydenham chorea and other forms of rheumatic fever. There may be association with other neuropsychiatric symptoms such as ADHD, motoric hyperactivity, anxiety, sensory abnormalities, concentration difficulties, irritability, and emotional labiality. These symptoms are accompanied by positive anti-GABHS antibodies and Streptococcal culture.

 

Study Design

This is an observational clinical study in which one hundred and fifty subject male and female subjects aged 3-21 years old suspected of having PANDAS will be enrolled. They will present to the Spectrum Neuroscience and Treatment Institute for explanation of the study, obtaining of signed consent/assent forms, medical history, information about medications taken, completion of questionnaires and consent to collect their clinical history from previous treating physicians. The study subjects will then go to a Quest Diagnostics laboratory to have blood drawn and throat swabs collected. The patients who are positive for anti-Strep antibodies will be referred back to their clinicians for appropriate treatment. The subjects who have tested positive for Anti-Strep antibodies and who were treated by their clinician will return to Spectrum again after 3 months to complete additional questionnaires, and go to a Quest Diagnostics lab to repeat the clinical laboratory blood work. This 3-month time period is chosen because it sufficient for treatment of the Streptococcal infection and PANDAS. Serum and plasma will be archived upon consent for possible subsequent testing as relevant analyses are identified. The patients’ clinicians will send information about the tonsillectomy/adenoidectomy and clinical history to the Spectrum Neuroscience and Treatment Institute where the collection, analysis and interpretation of all data will be carried out. Patients who are already diagnosed with PANDAS and have received treatment in the past will only complete the initial visit and a single blood draw and throat swabs collection.

 

Selection and Enrollment of study subjects:

    

       Inclusion Criteria:

  1. Male or female patients aged 3-21 years old
  2. Suspected of, or already diagnosed with, PANDAS

 

       Exclusion Criteria:

  1. Inability or unwillingness of subject or parent/caregiver to give written informed consent.
  2. Inability to tolerate venipuncture.

 

       Study Tasks: 

  1. Full blood work and throat cultures for Streptococcal infection on those children who have, or who are suspected of having, PANDAS
  2. History of tonsillectomy/adenoidectomy and of pre-and post-tonsillectomy strep tests
  3. History of treatment
  4. Clinical History of OCD, PANDAS, tics, ADHD, disruptive behavior
  5. Complete Medical History
  6. Completion of optional questionnaires related to diagnosis, including the following

–          Spence Children’s Anxiety Scale

–          Spence Children’s Anxiety Scale (Parent Report)

–          Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) Symptom Checklist and Severity Rating Scale

–          Yale Global Tic Severity Scale

  1. Repeated full blood work and throat cultures on those children who are initially diagnosed with PANDAS through the study blood work, test positive for anti-Strep antibodies and who have received appropriate treatment by their clinician (completed after three months of treatment).
  2. Data entry and analysis of all information collected including blood test results, questionnaire results, patient medical history and medications

 

Clinical and Laboratory Evaluations

The initial evaluation will include clinical history, questionnaires and clinical lab testing. Patients (n = 150) with, or suspected of having, a PANDAS diagnosis will go to Quest Diagnostics for blood draw and throat culture that will test for:

–          Anti-Streptococcal group A antibodies (ASO, DNAse B)

–          CBC and differential, including eosinophil count

–          Immunophenotyping by flow cytometry: CD3, CD4, CD8, CD19, CD16/56, CD3/CD4/CD45RA, CD3/CD8/CD45RA, CD3/CD4/CD45RO, CD38

–          Throat swab, Streptococcal group A culture

–          Throat swab, Streptococcal group A DNA

–          C3, C4, CH50, AH50, mannose binding protein

–          Cytokines: Interleukin 2, Interleukin 4, Interleukin 5, Interleukin 6, Interleukin 10, Interleukin 12p20, Interferon gamma, Tumor Necrosis Factor 

–          Autoantibody levels: Ri, Hu, Yo, Aquaporin 4, NMDR1, AMPAR, mGlut, GABA, CV2, Amphiphysin, Ma2/Ta

–          Paxgene DNA and RNA

–          Peripheral blood mononuclear cells will be isolated from whole blood supplemented with EDTA and cryostored

–          Serum and plasma will be archived for possible subsequent testing.

 

Specimens will be collected at initial evaluation. For patients who are initially diagnosed and who have received three months of treatment for their PANDAS diagnosis from their treating clinician will complete a second set of questionnaires and blood work/throat swabs at the completion of 3 months of therapy. The specimens will be received, processed and stored in the Clinical Correlations Department or the Research & Development Immunology Group. The results of the validated testing will be reported to the Researcher under Standard Operational Procedures. The results of testing by the Research & Development group will be reported to the Researcher by summary report.

 

Clinical and Medical History will provide the following data:

–          Demographics (age, gender, ethnicity)

–          Diagnosis, including symptom spectrum and evaluation instrument assessments

–          Co-morbidities, Medication and surgical history

–          Time since onset of PANDAS symptoms

 

Informed Consent

Subjects will include those diagnosed with, or suspected of having, PANDAS and a parent, caregiver, or guardian identified by the subject to provide the clinical team with information about the subject and his/her diagnosis. Children aged 7 to 12 will complete an assent form.  Children aged 12 to 18 with capacity to consent will sign the consent form with their Parents/Caregivers/Guardians co-signature; and those aged 18 to 21 will sign a consent independently and will not require a parent co-signature. Parents/caregivers/guardians will sign a separate consent that lists them as an informant for the study. As an informant they will complete assessments, via questionnaire or interview with a clinician, that discuss their child’s current and past behavior, current and past symptoms and diagnostic history including the following: medical history/demographic, concomitant medications for their child, and clinical assessments for PANDAS.

 

Medical History will be obtained from the subjects at the initial visit at The Spectrum Neuroscience and Treatment Institute (SNTI) and will also be collected from the treating physicians.

 

Treatment History and information about concomitant treatments will be obtained from the patients at the initial visit at SNTI and will also be collected from the treating physicians.

 

Clinical Assessments will be completed by a member of the research team at the beginning of the study and at the specified time points in the following table, and may include questionnaires about OCD, PANDAS, ADHD, tics, and disruptive behavior.

 

Safety Measures, Risks and Benefits

This is an observational study and no treatment will be provided as a part of this study.  Potential risks include the following:

  • Blood Draw: Risks of a blood draw include pain or bruise at the site of venipuncture, bleeding, swelling, itching and slight inflammation.  In rare cases it may result in an infection.
  • Loss of Confidentiality: All possible steps are taken to protect your information and confidentiality.  Information is stored in secure cabinets or computers to which only authorized personnel have access. All information will be de-identified and will only be linked via a study identifier.  However, there is a risk of loss of confidentiality if these safety measures are breached.
  • Patients may feel uncomfortable discussing personal or sensitive information that is related to questionnaires or interviews.  All efforts will be made to make patients comfortable.

 

Statistical Considerations:

 

The different groups will be compared using regression analyses and analyses of variance and statistical software program.

 

      

 

Schedule of Evaluations

 

Evaluation

Screening/Entry

 

1 mo.

2

mo.

3 mo.

Second Visit

Informed Consent

X

 

 

 

 

I/E Criteria

X

 

 

 

 

Medical and Treatment History

X

 

 

 

X

Tonsillectomy History

X

 

 

 

X

Vital Signs

X

 

 

 

X

Labs at Quest (Blood and Throat Swabs)

X

 

 

 

X

Throat Cultures

X

 

 

 

 

Questionnaires

X

 

 

 

X

Adverse events

X

 

 

 

X

 

 

 

References

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