Medical understanding

What throats can tell us

A condition associated with the common sore-throat bug Streptococcus can lead to obsessive behaviour. Its worth taking into consideration in children with autism and it can be treated, says Dr Daniel Goyal
Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) is a recently discovered condition in which an infection leads to obsessive behaviours. The common bug, Streptococcus, is associated mainly with tonsillitis and sore throats. In some, the infection triggers antibodies that, while fighting the infection, also have an impact on the brain. Classically, there is a clear history of sudden-onset obsessive behaviour following a sore throat; remission of obsessions generally follows resolution of the infection. In terms of our children with autistic spectrum disorder (ASD), it is a useful diagnosis to consider. PANDAS can be diagnosed clinically, and there is a clear and reasonably accurate array of lab tests to confirm it. Also, it usually responds to antibiotics (azithromycin, penicillin or a cephalosporin), and there is some evidence it may respond to milder antimicrobials such as olive leaf extract or sage. The tests can be performed at any GP surgery or hospital, and include: ASOT (a strep antibody test), Anti-DNAse B (another antibody test), or a throat swab. In its classical form, and that is to say its diagnosis, it is uncommon in ASD. A small percentage of those with obsessive-compulsive disorder
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

Key issues
If there is a sudden onset of obsessive behaviours and then a fairly sudden resolution, you should contact your paediatrician and raise the possibility of PANDAS If there is marked obsessive behaviour, then one must consider Streptococcus. Is the throat sore, or red? Are the glands up? There is a difference between repetitive behaviour and obsessive behaviour. Obsessive is more complex, and when interrupted usually causes more distress Other infections are probably able to cause obsessive issues Generally, improving the immune system should be helpful, but it can lead to a flare-up of symptoms. Insist someone looks at the throat/ tonsils. A blood test taken during the flare-up is useful Antibiotics may be needed to get the immune response settled down. While this is not ideal, remember that herbal remedies are antibiotics too. Support the gut, and monitor the results. Contacts, such as other family members, may need to be screened and/or treated to stop any re-infection Some suggest Streptococcus may also be present in other sites such as the ear or bowel. If so, an antibody test will be required to identify it There are other treatment methods available, such as a tonsillectomy, but these need expert advice and patient consideration.

(OCD) behaviour and ASD do fulfil the criteria for diagnosis (probably less than 10%). However, PANDAS raises some useful questions for ASD, and particularly for those with obsessive behaviours. First, the discovery of Streptococcus as a cause for a mental health condition has been quite a milestone. A disease that would previously have been treated through psychology or psychopharmacology, often quite successfully, can now be treated through antibiotics. The immune system, it would seem, can have marked effects on behaviour. This finding is further reinforced by a recent study on mice, in

which the immune system was exchanged in mice suffering OCD, with resolution of the OCD. The experiment was not done to propose exchanging the immune system as a treatment modality, but to emphasise that immunomodulation may well be a good route to explore in, at least, OCD.

The immune system, it would seem, can have marked effects on behaviour
from performing adequately. This usually leads to prolonged and unusual responses to infections. Therefore, it may be that some children develop obsessive-type behaviours or thoughts secondary to infection, but the behaviour does not fully resolve or suddenly improve. The infection (Streptococcus, for example) may not resolve as it does in a healthier immune system, and hence the sudden onset and sudden remission may not occur
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Immunotoxicity
The second question pertains to the inability of some children to get rid of infections or respond adequately to them. In our patient group this is usually down to immunotoxicity, and this essentially means the immune system is inhibited by an environmental toxin
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either. Instead, there may be a slow-burn OCD-type issue that may fluctuate with a fluctuating immune system. Our added difficulty is that often our children cannot communicate the sore throat or, indeed, cannot perceive it as a sore throat. The third issue raised here pertains to the actual mechanism of illness. PANDAS is classed as an autoimmune condition. That is, the immune system overreacts to

an infection, with some issue causing cross-reactivity. It is almost an exaggerated immune response. If the immune system is impaired, such as is present in a sub-group of ASD children, then the full extent of what is actually there (such as Streptococcus) may only be realized once the immune system starts to recover. Often, we witness children doing well apart from the obsessive side, or that when nutrition improves the immune response obsessions start to flare-up. This is the time to screen them for Strep-induced behaviour problems, or, indeed, other infections such as Clostridia, yeast or HHV-6.
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