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ANNALS OF CLINICAL PSYCHIATRY

LETTERS TO THE EDITOR

Annals of Clinical Psychiatry | Vol. 22 No. 4 | November 2010 283

Stuttering onset associated with streptococcal infection: A case suggesting stuttering as PANDAS

Gerald A. Maguire, MD; Steven N. Viele, MD, FAAP; Sanjay Agarwal, MD; Elliot Handler, BA; David Franklin, PsyD

W e report the case of a 6-year-old male with the sudden onset of stuttering approxi-mately 1 month after a documented strep-

tococcal 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 mal-aise. 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 par-ents 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 characteris-tic 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 con-tinued 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 antideoxyribonu-clease 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 individu-als may be viewed as pediatric autoimmune neuropsy-chiatric disorder associated with streptococcal infections (PANDAS).1 The hypothesis involves that the antibodies created to fight the infection cross-react with the devel-oping basal ganglia—a region of the brain implicated in stuttering etiology.2,3 PANDAS are characterized by a wax-ing/waning course, proposed involvement with the basal ganglia, pediatric onset, and neuropsychiatric symptoms often involving tic-like motions, all of which are associ-ated 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 associ-ated with mixed results.4 Although, the concept of PAN-DAS in other disorders remains open to debate, further research is indicated into this possible etiology of stutter-ing in a sub-set of individuals.4 ■

DISCLOSURES: Dr. Maguire receives grant/research sup-port 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 Laborato-ries and is a consultant to Endo Pharmaceuticals. Drs. Agarwal and Viele and Mr. Handler report no finan-cial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ANNALS OF CLINICAL PSYCHIATRY 2010;22(4):283-284

1. Mell LK, Davis RL, Owens D. Association between streptococcal infection and obsessive-compulsive dis-order, Tourette’s syndrome, and tic disorder. Pediatrics. 2005;116:56-60.2. Church AJ, Dale RC, Lees AJ, et al. Tourette’s syn-drome: a cross sectional study to examine the PANDAS

hypothesis. J Neurol Neurosurg Psychiatry. 2003;74: 602-607.3. Maguire GA, Riley GD, Yu BP. A neurological basis of stuttering. Lancet Neurol. 2002;1:407.4. Kurlan R, Kaplan EL. The pediatric autoimmunce neuropsychiatric disorders associated with strep-

tococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004;113:883-886.

REFERENCES

ANNALS OF CLINICAL PSYCHIATRY

LETTERS TO THE EDITOR

November 2010 | Vol. 22 No. 4 | Annals of Clinical Psychiatry 284

Gerald A. Maguire, MDAssociate Professor of Clinical PsychiatryKirkup Endowed Chair in Stuttering TreatmentSenior Associate Dean, Educational AffairsUniversity of California, Irvine Medical CenterOrange, CA, USA

* At the time of this letter, Drs. Agarwal and Franklin and Mr. Handler were at these respective affiliations.

Sanjay Agarwal, MD*ResidentUniversity of California, Irvine Medical CenterOrange, CA, USA

Steven N. Viele, MD, FAAPPediatricianPrivate PracticeLaguna Beach, CA, USA

David Franklin, PsyD*Assistant Clinical ProfessorDepartment of PsychiatryUniversity of California, Irvine Medical CenterOrange, CA, USA

Elliot Handler, BA*StudentUniversity of California, Irvine Medical CenterOrange, CA, USA

CORRESPONDENCE: Gerald A. Maguire, MD, University of California, Irvine Medical Center, Department of Psychiatry,

101 The City Drive, Orange, CA 92868 USA, E-MAIL: gamaguir@uci.edu

In this issue of

FACULTY CHAIR Henry A. Nasrallah, MDProfessor of Psychiatry and NeuroscienceUniversity of Cincinnati College of MedicineCincinnati, Ohio FACULTYJoseph F. Goldberg, MDAssociate Clinical Professor of PsychiatryMount Sinai School of MedicineNew York, New York

CME REVIEWER Christoph U. Correll, MDMedical DirectorRecognition and Prevention (RAP) ProgramThe Zucker Hillside HospitalAssociate Professor of PsychiatryAlbert Einstein College of MedicineBronx, New York

Differential Diagnosis and Therapeutic Management of Schizoaffective Disorder

Jointly sponsored by Albert Einstein College of Medicine, Montefiore Medical Center, and Asante Communications, LLC.

This activity is supported by an educational grant from Janssen, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc, administered by Ortho-McNeil-Janssen Scientific Affairs, LLC. It was peer reviewed by AnnAls of CliniCAl PsyChiAtry.

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