The Journal of the Arkansas Medical Society Med Journal April 2020 | Page 13

pam and then transferred to a tertiary children’s
hospital. On physical examination, there was facial
grimacing and prominent choreoathetoid move-
ments in bilateral upper and lower extremities.
There was absence of rigidity, lip smacking/puck-
ering, cog wheeling, dystonia, and hyperreflexia.
The mother reported the patient had a long his-
tory of recurrent streptococcal infections includ-
ing a confirmed streptococcal infection several
months prior to this admission, which was treat-
ed with a 10-day course of amoxicillin. The MRI
was unremarkable, and the EEG showed mild
slowing. Laboratory findings were remarkable
only for elevated creatine kinase 661 (4-87 U/L)
and mildly elevated CRP 22.8 (0.0-10.0 mg/L).
His rapid antigen streptococcal test (RAST), ASO
titre (< 25), and ADB titre (<86) were negative.
WE-D from decreasing quetiapine dose and/
or a movement disorder complicated by PAN-
DAS is a plausible explanation of the patient’s
abnormal movements. Sydenham’s Chorea is
also high on the differential. Treatment was ini-
tiated by increasing quetiapine up to 200 mg PO
BID, which led to gradual improvement of ab-
normal movements. A trial of antibiotic therapy
was recommended by the psychiatry consults
Table
team; however, patient showed objective signs
of improvement with quetiapine titration alone.
At an outpatient three-month follow up visit, re-
cords indicate that the patient is stable on the
quetiapine without any abnormal movements.
current or post-streptococcal infection. These
movements could be understood as either PAN-
DAS, SC, or WE-D or a combination of all three
conditions. Both patients responded to increasing
doses of quetiapine. We hypothesize that the sud-
den onset of these three rare conditions resulted
from the reduction of antipsychotics in the con-
text of post-streptococcal infection, leading to a
severe PANDAS syndrome. The clinical implica-
tion is that clinicians should consider prophylactic
treatment with antibiotics for complex psychiatric
syndromes with recurrent strep infection, take
caution in reducing antipsychotics in this popu-
lation, and that the presentation of SC may be a
manifestation of a PANDAS syndrome.
References
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Discussion
It is postulated that neuro inflammation plays a
major role in the etiology and pathogenesis of
PANDAS. 6 Serum IgG from patients with SC and
PANDAS, which bind to components of the group
A Streptococcus cell wall, have also been shown
to cross-react with neuronal components in the
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pallidus. 7 The PANDAS Consortium recommends
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Jennifer F, Susan S, Tanya M, C. DR, Dritan A,
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Both cases involved patients with a long history
of complex and comorbid psychiatric diagnoses
treated with multiple medications and changing
doses of medications along with a concomitant
history of recurrent streptococcal infections.
In both cases, changes to the dose of antipsy-
chotic, which had never been problematic pre-
viously, was followed by SC and PANDAS when
the decrease in antipsychotic occurred during
Volume 116 • Number 10
ric Acute-Onset Neuropsychiatric Syndrome:
Part I—Psychiatric and Behavioral Interventions.
Journal of Child and Adolescent Psychopharma-
cology. 2017;27(7):566-73.
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