Strep Infection Affecting Behavior in Children (Copy)
What’s the big deal about Strep?
We’ve all heard of strep throat. Maybe even been diagnosed with it a time or two. Its a pretty common childhood infection that most of the time ends up resolving without sequelae after a short course of antibiotics. But we are learning that Group A Strep (GAS), the type of bacteria responsible for this infection has some extra ‘abilities,’ that can create complications in children following infection - especially in cases where the children are asymptomatic and go without treatment for an extended period of time.
While most individuals who experience a GAS infection develop symptoms such as sore throat, fever, chills, headache, possibly even abdominal pain, vomiting or rash, sometimes kiddos can be completely asymptomatic while harboring a strep infection. This actually happened to my son this past year. I had been getting messages from his kindergarten teacher several times a week regarding his ‘mischievious’ behaviors. She confirmed that these were more than to be expected from the average active 5-6 year old boy. At home he was almost always in an awful mood, oppositional to the point of just toeing the line to see what he could get away with, and hyperfixated on curse words - like listening to music with profanity if he could get away with it and getting other kids to repeat those words at school - he was nearly obsessed with things he knew he wasn’t supposed to do, say or watch. We were in for a behavioral assessment per his teacher’s recommendation, and the pediatrician noticed his weight was down a few pounds. He denied any discomfort, but I mentioned he had seemed to be urinating more frequently (although not increasingly thirsty). She ordered a urinalysis and found there was moderate blood in his urine. Based on the blood, she ordered a rapid strep test (hematuria can follow a GAS infection). The rapid came back negative but culture popped positive for GAS.
Following the positive strep culture, we gave him a complete course of amoxicillin, which was challenging for me to agree to since he was asymptomatic…but strep is an infection that if we have confirmation of its existence, we really do need to address it. Left untreated, unpleasant things can happen. More to come on that.
This treatment took place over Christmas break. By the time the kids returned back to school, I was noticing gradual improvements in his behavior, but I thought it might be because of being home and having so much time together as a family and him receiving plenty of attention. His teacher remarked on the change in him as well. He was on a behavior check-in sheet daily that involved tallying behavior points to see if he could meet or exceed his points goal for each day. His goal was 46. Prior to treatment he was getting probably 30-40 points out of 56. Since eradicating the strep infection he has missed maybe 1-2 points almost every day, often getting a perfect score, and with the worst day being a substitute teacher when he earned only a 50 (less structure, off schedule, new person, etc). His teacher cannot get over his change in behavior. And he now asks us to quickly change the channel if he even hears an ‘almost’ curse word. He sits and builds legos for hours, asks to be a helper at school, and is patient and able to redirect himself when his brother is pushing his buttons. In the past, this would have been an emotional meltdown, often resulting in physical retaliation with a closed fist.
How does strep affect the brain if it lives in the throat?
You might have heard of a condition called rheumatic fever - very rare to see in the developed countries because we tend to (unfortunately) treat every kid with a sore throat with antibiotics even without testing or with a negative test. Rheumatic fever is an immune-mediated disease that occurs primarily as a complication of GAS infections. This is more common when strep infections aren’t treated immediately or completely. Complications with rheumatic fever occur because of what we refer to as a ‘virulence factor’ possessed by Group A Strep (GAS), which causes antibodies that the body creates toward a protein on the cell wall of the strep bacteria to also attack our own native tissue. This can affect the heart tissue and valves by chemicals called cytokines that are released by our immune system in an effort to destroy the invader. Because of this ‘molecular mimicry’ by the bacteria, the immune system reacts not only to the strep molecules but also to the human host molecules that were mimicked; an example of ‘cross-reactive’ antibodies. So basically, the body starts attacking itself (the innocent bystander) while trying to fight off the enemy. This is the foundational concept of most autoimmune diseases.
Studies at the National Institute of Mental Health (NIMH) and elsewhere have shown that some cross-reactive antibodies target the brain, accounting for the neuropsychiatric symptoms that can develop during/following infection. The basal ganglia has been suggested by MRI imaging in studies of children with neuropsychiatric symptoms following GAS infection to incur the greatest deal of inflammation. These conditions cause by GAS are referred to as PANDAS ( Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections)- however, Pediatric Acute-onset Neuropsychiatric Syndrome, or PANS, is an overlying group that has described the development of the same spectrum of symptoms following other infections like Lyme disease or Epstein Barr (mono), even Influenza A.
Severe cases of PANS/PANDAS cause symptoms such as dramatic behavioral changes, like the sudden onset of tics, OCD symptoms, bedwetting, and separation anxiety. More mild cases can be less obvious but cause increased trouble at school due to deterioration of learning abilities, developmental regression, aggression, irritability, emotional lability, oppositional behavior, urinary frequency, and sleep disturbances. I have heard of and worked with kids who have had the more severe and evident symptoms following a known infection with sore throat and fever, but it just wasn’t on my radar with my son being asymptomatic. Now I wonder what if he had never been tested and treated? Would it have worsened, or self-resolved? The results could be different for each kid depending on the how robust their immune system and what other factors might be taxing their immune reaction, such as other latent infections like Lyme or even environmental toxins (ie from processed foods, pesticides, personal care products, etc).
So do we just go around routinely testing kids for GAS? I don’t think so, but education and awareness are key. We (in the medical field) have previously assumed these autoimmune/inflammatory reactions to be relatively rare, and I’ve worked with several kiddos who were brushed off by their pediatricians because they didn’t believe in or understand the PANS/PANDAS existence. PANS and PANDAS are thankfully becoming increasingly recognized in the clinic and multiple parent interest groups are presently active in several European countries. A USA 2015 consensus paper for the diagnostic work-up recommended a broad assessment including psychiatric, immunological and infectious disease evaluation. However, some parts of these recommendations (i.e. the blood tests recommended) have been criticized for not being based on published patient data, The National Institute for Health and Care Excellence guidelines on OCD mention PANDAS, but do not provide a comprehensive description or any clinical guidelines.
A rapid strep test doesn’t always catch GAS infection if the child is asymptomatic. Some alternative tests that can be performed include an anti-strep antibody titer (i.e., the number of molecules in blood that indicate a previous infection), but this only tells us whether the child has ever had a previous strep infection. Sometimes based on the levels we can assume its been a recent infection, but its not always reliable because some children have 'positive' antibody titers for many months after a single infection.
A functional test that has been used fairly successfully in the functional medicine world is the Neural Zoomer, which measures immune reactivity to structures, tissues, cells, and chemicals in the brain and peripheral nervous system. This test can detect underlying inflammatory responses that may be causing symptoms related to mood, memory, aging, balance, nervous function, movement, pain, and more.
In addition, a thorough symptoms analysis and medical history may be enough to warrant a trial course of treatment. In addition to antibiotics (with good support of gut flora during treatment), a focus on nutritional support and management of other potential toxins contributing to inflammation can help mediate symptoms.
So what if you suspect your child is suffering from PANS/PANDAS but your pediatrician doesn’t understand or want to consider these conditions? You can look for a physician who specializes in the PANDAS Physicians Network (https://www.pandasppn.org/), or you can reach out to chat with me about working one-on-one to assess/manage the condition. Trust me, having been through it myself (albeit on a mild scale), I can’t tell enough people about this experience. Imagine your kiddo suffering from mental health and behavioral issues because of a sneaky little bacterial infection we have the tools to easily treat...
https://www.nimh.nih.gov/health/publications/pandas
https://pmc.ncbi.nlm.nih.gov/articles/PMC6401534/https://pmc.ncbi.nlm.nih.gov/articles/PMC6401534/
https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2020.00564/full