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Antiphosphatidylethanoline Antibody in a PANDAS-Like Condition
- Deborah K. Sokol, Lisa M. McGuire, Nathan S. Johnson, Dawn R. Wagenknecht; John A McIntyre, St Francis Hospital & Health Centers (12 April 2006)
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Deborah K. Sokol, Associate Professor; Pediatric Neurologist Indiana University School of Medicine, Indianapolis, IN, Lisa M. McGuire, Nathan S. Johnson, Dawn R. Wagenknecht; John A McIntyre, St Francis Hospital & Health Centers
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dksokol{at}iupui.edu Deborah K. Sokol, et al.
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Dear Editor, We read with great interest the investigation of RC Dale, et al. on the incidence of anti-brain antibodies in children with obsessive- compulsive disorder (1). In this study, high levels of anti-basal ganglia antibodies (ABGA) were found in serum from children with obsessive compulsive disorder (OCD) as compared to control groups of children with streptococcal infection without OCD, pediatric autoimmune disease and neurological disorders (stroke, movement disorders and encephalitis). These investigators concluded that central nervous system autoimmunity may play a role in a significant subgroup of children with OCD. Recently, we found another autoantibody, antiphosphatidylethanolamine (aPE), which may be associated with explosive onset of OCD in a five-year old girl. Six weeks prior to showing OCD symptoms, the girl was diagnosed with an ear infection, for which she received a full course of antibiotics. She presented at our clinic two months after the onset of OCD symptoms. Past medical history was significant for recurrent ear infection. Physical and neurologic examinations were normal; no tics were observed. There was no family history of OCD. At the index visit, the patient was negative for streptolysin O antibody. Throat cultures were negative for Streptococcus pyogenes and Streptococcus group A antigen. A test for deoxyribonuclease B, a marker for prior streptococcus infection, was negative. To investigate an autoimmune diathesis, the patient was tested for IgG, IgA and IgM aPE, antiphosphatidylserine (aPS), antiphosphatidylcholine (aPC) and anticardiolipin (aCL) (2). Serial antiphospholipid antibody (aPL) testing revealed persistent presence of IgG aPE antibodies (Table 1). The aPE antibody levels fluctuated coincident with the expression of her OCD symptoms. The index and day 113 sera were also positive for IgG aPS. The patient was begun on a low dose of sertraline and her OCD improved. We believe this patient has a PANDAS-like condition because the criteria, except for evidence of group A streptococcus infection, was met. With a history of repeated ear infections, her OCD symptoms occurred after the most recent ear infection. Without documenting the infectious agent, our patient mounted an autoimmune reaction suggested by elevated levels aPE antibody and the development of OCD after another ear infection. We have found aPE in other neuropsychiatric conditions. We reported the case of an adolescent girl with a basal ganglia stroke who had IgA aPE in her serum and IgG and IgA aPE in her cerebral spinal fluid (CSF). Subsequent to the stroke the patient experienced seizures and depression (2). Further, aPE was the most frequently detected antiphospholipid antibody in the serum of psychotic patients (3). Thirty three percent of CSF collected from this group of psychotic patients contained IgG aPE in the absence of this particular autoantibody reactivity in serum suggesting intrathecal synthesis of the aPE antibody. We propose that aPE may attack the basal ganglia leading to its association with OCD and other disorders of the brain. Although the finding of aPE antibodies with OCD is in a single patient, we believe, that aPE may be an additional autoimmune marker that should be considered with post-infectious OCD. We have no interests that would be forwarded by publication of this letter. References 1. Dale, RC, Heyman, I, Giovannoni, G and Church, AJ. Incidence of anti-brain antibodies in children with obsessive-compulsive disorder. British Journal of Psychiatry, 2005; 187: 314-319. 2. Sokol, DK, McIntyre, JA, Short, RA, Gutt, J., Wagenknecht, DR, Biller, J., Garg, B. Henoch-Schonlein purpura and stroke: antiphosphatidylethanolamine antibody in CSF and serum. Neurology, 2000; 55: 1379-1381. 3. O'Brien, R.S., Sokol, D.K., Wagenknecht, D.R., Rao. T.V. and McIntyre, J.A. Antiphospholipid antibody (APL) in serum and CSF from patients with psychosis. Thromb Research, 2004; 114:629. 4. McIntyre JA, Wagenknecht DR, Waxman DW. Frequencies and specificities of antiphospholipid antibodies (aPL) in volunteer blood donors. Immunobiology 2003;207:59-63 |
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