Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated With Group A Streptococcus

Tanya K. Murphy, MD, MS; Adam B. Lewin, PhD; E. Carla Parker-Athill, PhD; Eric A. Storch, PhD; P. Jane Mutch, PhD

Disclosures

Pediatr Infect Dis J. 2013;32(8):834-838. 

In This Article

Abstract and Introduction

Abstract

Background: In children presenting with obsessive compulsive disorder (OCD) and/or tics, especially those with a temporal association with streptococcal pharyngitis (eg, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus), there is speculation about whether tonsillectomy/adenoidectomy might improve the child's neuropsychiatric course. Our objective was to examine whether removal of the tonsils and/or adenoids impacted streptococcal antibody titers, the timing of onset of OCD and/or tics and the clinical severity of these symptoms.

Methods: Study participants (N = 112; average age = 9.2 ± 2.4; 44 women) were recruited as part of a prospective investigation of neuropsychiatric phenomena with temporal association to streptococcal pharyngitis and examined by family history, diagnostic interview, physical examination, medical record review, psychological testing and streptococcal antibodies and divided into surgical or nonsurgical groups. The surgical group consisted of children having previously had a tonsillectomy and/or adenoidectomy (n = 32). The remaining children were categorized as nonsurgical group (n = 76). Measures of OCD and tic severity, streptococcal antibody titers and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification were compared between both groups.

Results: There were no significant differences as determined by streptococcal antibody titers, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification and OCD or tic severity between the surgical and nonsurgical groups. Most participants had surgery before the onset of neuropsychiatric symptoms and surgery did not affect symptomology.

Conclusions: Streptococcal antibodies and neuropsychiatric symptom severity did not differ on the basis of surgical status. From these data, we cannot infer that tonsillectomy and adenoidectomy are likely to impact positively the course of OCD/tics or streptococcal antibody concentrations.

Introduction

Pharyngitis is a common pediatric medical complaint with 15–30% of infections attributed to group A streptococcus (GAS).[1] Although a relatively mild illness, untreated GAS pharyngitis can lead to more serious conditions, including acute glomerulonephritis, rheumatic fever and Sydenham chorea (a neurological presentation of rheumatic fever). Similarly, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS), a proposed subtype of obsessive compulsive disorder (OCD)/tics, has been temporally associated with GAS pharyngitis.[2] To prevent the progression from GAS infection to these chronic morbidities, prompt antibiotic intervention remains the primary course of treatment to eradicate the GAS infection.[3] In PANDAS patients, antibiotic treatment of GAS infection has been shown to improve neuropsychiatric symptoms of OCD and tics.[4,5]

Tonsillectomy and adenoidectomy have also been considered a treatment alternative for the aforementioned infection-mediated conditions (eg, GAS, rheumatic fever) since the early 1900s[6] and are becoming a more common recommendation as a viable treatment option for PANDAS[7–9] without empirical support. Severe recurrent infections (7 or more episodes in the preceding year, 5 or more in the preceding 2 years or 3 or more in the preceding 3 years), a common feature in PANDAS patients, is often a common indication for surgery.[10] Despite this connection, there is still disagreement as to its efficacy of this treatment option in alleviating these symptoms, and little evidence to support its efficacy in PANDAS.[8,11,12] However, in pathologies resulting from hypertrophy, the necessity for surgery in obstructive conditions is accepted as a viable and necessary therapeutic option as morbidity may be reduced and even eliminated through surgery.[10,13]

Surgical treatment modality has been prompted by case reports citing reductions in the symptoms of OCD and tics following surgery,[11] as well as reported decreases in the recurrence of GAS pharyngitis.[11,14] Whereas guidelines exist for tonsillectomy and/or adenoidectomy for the treatment of recurrent GAS pharyngitis,[10] no clinical standard exists for using this treatment for symptoms of OCD and/or tics without the presence of indications per the established guidelines.

The objective of the present research was to examine whether removal of the tonsils and/or adenoids influenced the clinical presentation (eg, streptococcal antibody levels, the timing of symptom onset and symptom severity) of OCD and tics in PANDAS patients. We hypothesized that removal of the tonsils and/or adenoids does not reduce titer elevations or decrease the intensity of neuropsychiatric symptoms (eg, OCD or tics) associated with PANDAS.

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