LETTERS TO THE EDITOR
Stuttering onset associated with streptococcal infection: A case suggesting stuttering as PANDAS
Associate Professor of Clinical Psychiatry, Kirkup Endowed Chair in Stuttering Treatment, Senior Associate Dean, Educational Affairs, University of California, Irvine Medical Center, Orange, CA, USA
Pediatrician, Private Practice, Laguna Beach, CA, USA
Resident, University of California, Irvine Medical Center, Orange, CA, USA
Student, University of California, Irvine Medical Center, Orange, CA, USADavid Franklin, PsyD*
Assistant Clinical Professor, Department of Psychiatry, University of California, Irvine Medical Center, Orange, CA, USA
* At the time of this letter, Drs. Agarwal and Franklin and Mr. Handler were at these respective affiliations.
ANNALS OF CLINICAL PSYCHIATRY 2010;22(4):283–284
We report the case of a 6-year-old male with the sudden onset of stuttering approximately 1 month after a documented streptococcal infection. The patient had no known family history of stuttering. Six months prior to an evaluation for stuttering, the patient presented to his pediatrician for complaints of a sore throat, fever, and general malaise. A rapid streptococcus antigen test was performed at the time and was found to be positive (Genzyme Strep A Test OSOM). Choosing to avoid medications, the parents declined antibiotics. One month later, the patient developed the acute onset of stuttering characterized by sound and syllable repetitions and silent blocking of speech. Three months later, he developed characteristic struggle behaviors of stuttering, facial grimaces and head twitches when a stuttering event occurred while speaking. Five and one-half months after his initial diagnosis of a streptococcal infection, the patient continued to have a positive rapid streptococcus antigen test, an antistreptolysin O (ASO) titer of 400 IU/ml (age-specific normal <200 IU/ml) and an antideoxyribonuclease B (anti-DNase B) titer of 387 U/ml (normal=0 to 70 U/ml). He then began amoxicillin/clavulanic acid, 800 mg/d for 10 days with near resolution of stuttering symptoms within 2 weeks. Streptococcal throat culture after the antibiotic course was negative. The patient remained without stuttering symptoms at the time of this submission (6 months later).
This case illustrates that stuttering in some individuals may be viewed as pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS).1 The hypothesis involves that the antibodies created to fight the infection cross-react with the developing basal ganglia—a region of the brain implicated in stuttering etiology.2,3 PANDAS are characterized by a waxing/waning course, proposed involvement with the basal ganglia, pediatric onset, and neuropsychiatric symptoms often involving tic-like motions, all of which are associated with stuttering. This case is the first described in the literature of a documented streptococcal infection preceding stuttering weeks prior to onset. This patient’s recovery may have been spontaneous and unrelated to antibiotic therapy, which, in PANDAS, has been associated with mixed results.4 Although, the concept of PANDAS in other disorders remains open to debate, further research is indicated into this possible etiology of stuttering in a sub-set of individuals.4
DISCLOSURES: Dr. Maguire receives grant/research support from Otsuka America Pharmaceutical, Inc., Endo Pharmaceuticals, Merck, and Eli Lilly and Company; is a consultant to Merck, Eli Lilly and Company, Endo Pharmaceuticals, and Teva Pharmaceutical Industries Ltd.; and is a speaker for Merck, Novartis, and Eli Lilly and Company. Dr. Franklin receives grant/research support from Otsuka America Pharmaceutical, Inc., Endo Pharmaceuticals, Merck, and Abbott Laboratories and is a consultant to Endo Pharmaceuticals. Drs. Agarwal and Viele and Mr. Handler report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
- Mell LK, Davis RL, Owens D. Association between streptococcal infection and obsessive-compulsive disorder, Tourette’s syndrome, and tic disorder. Pediatrics. 2005;116:56–60.
- Church AJ, Dale RC, Lees AJ, et al. Tourette’s syndrome: a cross sectional study to examine the PANDAS hypothesis. J Neurol Neurosurg Psychiatry. 2003;74: 602–607.
- Maguire GA, Riley GD, Yu BP. A neurological basis of stuttering. Lancet Neurol. 2002;1:407.
- Kurlan R, Kaplan EL. The pediatric autoimmunce neuropsychiatric disorders associated with streptococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004;113:883–886.
CORRESPONDENCE: Gerald A. Maguire, MD, University of California, Irvine Medical Center, Department of Psychiatry, 101 The City Drive, Orange, CA 92868 USA, E-MAIL: firstname.lastname@example.org
Annals of Clinical Psychiatry ©2010 Quadrant HealthCom Inc.