Pediatric autoimmune neuropsychiatric disorders after streptococcus infection
A 10 year-old girl presented to the pediatric outpatient department with chief complaints of abnormal involuntary movements involving the face and shoulder for the last 4 weeks. Around 1 week prior to these complaints, the patient had an episode of high-grade fever with throat pain. Few days after the resolution of fever, the parents noticed involuntary movements involving the face and shoulder. Movements were sudden, rapid and non-rhythmic. As per the parents, these movements were present whenever the child was awake. There was no history of loss of consciousness or head injury in the patient preceding or following the fever. Parents also reported that child cried too often for no apparent reason. Detailed psychiatric evaluation revealed that during the period of fever, the child had reported (even during remission of fever) fearfulness, seeing people coming to her, suggestive of visual hallucinations, which resolved spontaneously after 2-3 days. The child also showed withdrawn behavior along with emotional lability. Child was born of a non-consanguineous marriage after an uncomplicated pregnancy, full-term normal delivery at hospital. Regular immunizations were carried out. At birth, her weight and length were normal. Medical records and history suggested normal development. There was no family history of seizures or other abnormal movements/psychiatric complaints. On examination, the child was well oriented and higher mental functions were intact. Vitals were within normal limits. There were tic movements in both shoulders. Movements decreased but persisted when the child was observed in a restful state, with complete disappearance during sleep. Rest of the nervous system and other body systems were normal on examination. Hemoglobin (11.6 g/dl), total leukocyte count (8800/ mm3), differential leukocyte count (P58 L32 M8 E2), and erythrocyte sedimentation rate (11 mm fall in first hour) were within normal limits. Other blood investigations revealed normal sugar, electrolytes levels, and liver function tests. In view of recent past history of sore throat, anti-streptolysin O (ASO) titers were estimated and found to be high (350 Todd units).\nElectroencephalography (EEG) and magnetic resonance imaging (MRI) brain were normal. Thus, diagnosis of PANDAS syndrome was made, as our case met all the required diagnostic criteria [].\nInitially, the patient was treated with 10 mg Fluoxetine, but the child developed skin rashes all over, so in view of that it was stopped. Later, patient was started on Clonidine 0.1 μg ¼ QID and Clonazepam 0.25 mg BD. After 8 days of hospitalization, patient was discharged with a significant improvement. After a follow-up of 2 weeks, the patient was maintaining the improvement and is doing well at 3 months post discharge.