Letter to the Editor
The link between tics and streptococcal infection: A case report
Relación entre tics e infección estreptocócica: a propósito de un caso
E. Peña Llamas
Servicio de Neurología, Hospital Sanitas La Moraleja, Madrid, Spain
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"apellidos" => "Gazulla" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485312001892" "doi" => "10.1016/j.nrl.2012.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485312001892?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580813001491?idApp=UINPBA00004N" "url" => "/21735808/0000002800000009/v1_201311300021/S2173580813001491/v1_201311300021/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "The link between tics and streptococcal infection: A case report" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "592" "paginaFinal" => "593" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "E. Peña Llamas" "autores" => array:1 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Peña Llamas" "email" => array:1 [ 0 => "epenal.pex@sanitas.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurología, Hospital Sanitas La Moraleja, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Relación entre tics e infección estreptocócica: a propósito de un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tics are repetitive, stereotyped movements that may be suppressed voluntarily. Patients feel the need to perform them as a means of relieving a mental or physical sensation that precedes them<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>; the most frequent cause is Tourette syndrome (TS).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Researchers have tried to establish a link between tics and infection with Group A β-haemolytic streptococcus (GABHS).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> With this in mind, we present the case of a tic arising years after the patient had experienced Sydenham chorea (SC), a condition associated with GABHS, and we discuss the relationship between those episodes.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 9-year-old girl who had experienced acute predominantly right-sided chorea, preceded by changes in handwriting and scholastic achievement. Anti-streptolysin antibody (ASLO) titre 1152; echocardiography showing mild mitral regurgitation; normal brain MRI; normal ceruloplasmin; and normal metabolic and hormonal studies. After being diagnosed with SC, she was treated with haloperidol, which improved symptoms, but the chorea persisted during 2 years. Since that time, she has received monthly prophylactic treatment with penicillin G. At the age of 13, she reported motor disorder in the form of brusque dorsal flexion of the left ankle when walking, causing the joint to click. This event could be prevented voluntarily, although the patient felt inclined to provoke it in order to relieve a feeling of tension in that joint. Traumatology study yielded normal results. ASLO: 285 (similar to previous studies); pharyngeal exudate presented normal flora. Symptoms resolved spontaneously in 1 year without treatment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The role played by GABHS in tic aetiopathogenesis is a topic of debate. Tics are known to be movement disorders that are frequently associated with streptococcal infection; on some occasions, they meet diagnostic criteria for TS.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Nevertheless, the nature of this association is unclear.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For example, we know that GABHS may provoke SC, which is the neurological autoimmune manifestation of rheumatic fever; it presents with chorea and other neuropsychiatric symptoms<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and tics in some cases.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The same autoimmune mechanism may be involved in both syndromes. In fact, patients with SC have been described as being more susceptible to drug-induced tics than other patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Doctors have also indicated that children with a prior history of tics are more likely to develop Sydenham chorea.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In this sense, the autoimmune nature of this association between entities is reinforced by the concomitant finding of specific anti-basal ganglia antibodies and high ASLO titres in patients with TS.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Lastly, another argument supporting the presence of an autoimmune aetiopathogenic link between tics and streptococcal infection is the description of paediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDA). This disorder is defined by relapsing-remitting episodes of tics and/or obsessive-compulsive disorder associated with a recent streptococcal infection and attributed to an autoimmune mechanism,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> although whether or not it really exists is currently a very controversial topic.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In our case, the motor disorder described by the patient met clinical criteria for a tic, and was interpreted as a simple motor tic of the foot during walking. Such tics, while less frequent than others, have been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Therefore, the presence of SC and tics in the same patient suggests yet again the possibility of a link between tics and streptococcal infection; the novel finding in our case is that the tic appeared years after SC. This being the case, our patient may have developed an increased propensity for tics after having SC. This would probably have been caused by the presence of circulating anti-basal ganglia antibodies. The possibility of there being a relapsing-remitting PANDA process due to reinfection was less likely, since ASLO titres were not high at the time when the tic appeared, the pharyngeal exudate culture was normal, and the patient was being treated prophylactically with penicillin.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, although the association between tics and streptococcal infection is well-documented in the literature, the nature of that link is unclear, and further studies will be needed to offer an explanation.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-12" "fechaAceptado" => "2012-06-11" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Peña Llamas E. Relación entre tics e infección estreptocócica: a propósito de un caso. Neurología. 2013;28:592–593.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Definition and classification of hyperkinetic movements in childhood" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.D. Sanger" 1 => "D. Chen" 2 => "D.L. Fehlings" 3 => "M. Hallett" 4 => "A.E. Lang" 5 => "J.W. 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| 2021 July | 38 | 4 | 42 |
| 2021 June | 77 | 7 | 84 |
| 2021 May | 53 | 7 | 60 |
| 2021 April | 108 | 16 | 124 |
| 2021 March | 64 | 7 | 71 |
| 2021 February | 45 | 5 | 50 |
| 2021 January | 44 | 11 | 55 |
| 2020 December | 49 | 8 | 57 |
| 2020 November | 45 | 7 | 52 |
| 2020 October | 36 | 6 | 42 |
| 2020 September | 35 | 11 | 46 |
| 2020 August | 30 | 5 | 35 |
| 2020 July | 27 | 4 | 31 |
| 2020 June | 26 | 9 | 35 |
| 2020 May | 16 | 8 | 24 |
| 2020 April | 22 | 3 | 25 |
| 2020 March | 17 | 8 | 25 |
| 2020 February | 14 | 5 | 19 |
| 2020 January | 13 | 8 | 21 |
| 2019 December | 15 | 11 | 26 |
| 2019 November | 15 | 9 | 24 |
| 2019 October | 6 | 6 | 12 |
| 2019 September | 16 | 4 | 20 |
| 2019 August | 9 | 0 | 9 |
| 2019 July | 8 | 7 | 15 |
| 2019 June | 22 | 19 | 41 |
| 2019 May | 83 | 28 | 111 |
| 2019 April | 24 | 18 | 42 |
| 2019 March | 7 | 6 | 13 |
| 2019 February | 5 | 7 | 12 |
| 2019 January | 6 | 3 | 9 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 7 | 2 | 9 |
| 2018 October | 10 | 4 | 14 |
| 2018 September | 9 | 5 | 14 |
| 2018 August | 3 | 2 | 5 |
| 2018 July | 3 | 4 | 7 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 2 | 2 | 4 |
| 2018 April | 7 | 1 | 8 |
| 2018 March | 5 | 0 | 5 |
| 2018 February | 7 | 3 | 10 |
| 2018 January | 3 | 4 | 7 |
| 2017 December | 7 | 3 | 10 |
| 2017 November | 7 | 3 | 10 |
| 2017 October | 9 | 3 | 12 |
| 2017 September | 10 | 1 | 11 |
| 2017 August | 10 | 4 | 14 |
| 2017 July | 8 | 2 | 10 |
| 2017 June | 19 | 3 | 22 |
| 2017 May | 11 | 5 | 16 |
| 2017 April | 14 | 4 | 18 |
| 2017 March | 9 | 4 | 13 |
| 2017 February | 4 | 3 | 7 |
| 2017 January | 8 | 5 | 13 |
| 2016 December | 15 | 8 | 23 |
| 2016 November | 7 | 2 | 9 |
| 2016 October | 19 | 14 | 33 |
| 2016 September | 5 | 10 | 15 |
| 2016 August | 7 | 3 | 10 |
| 2016 July | 8 | 2 | 10 |
| 2016 June | 15 | 15 | 30 |
| 2016 May | 13 | 8 | 21 |
| 2016 April | 9 | 10 | 19 |
| 2016 March | 15 | 14 | 29 |
| 2016 February | 12 | 8 | 20 |
| 2016 January | 15 | 5 | 20 |
| 2015 December | 12 | 7 | 19 |
| 2015 November | 14 | 3 | 17 |
| 2015 October | 16 | 6 | 22 |
| 2015 September | 16 | 6 | 22 |
| 2015 August | 10 | 8 | 18 |
| 2015 July | 7 | 4 | 11 |
| 2015 June | 2 | 1 | 3 |
| 2015 May | 8 | 6 | 14 |
| 2015 April | 13 | 6 | 19 |
| 2015 March | 16 | 4 | 20 |
| 2015 February | 9 | 1 | 10 |
| 2015 January | 24 | 5 | 29 |
| 2014 December | 49 | 9 | 58 |
| 2014 November | 12 | 3 | 15 |
| 2014 October | 22 | 7 | 29 |
| 2014 September | 29 | 3 | 32 |
| 2014 August | 22 | 2 | 24 |
| 2014 July | 39 | 4 | 43 |
| 2014 June | 13 | 3 | 16 |
| 2014 May | 11 | 7 | 18 |
| 2014 April | 9 | 4 | 13 |
| 2014 March | 20 | 1 | 21 |
| 2014 February | 37 | 12 | 49 |
| 2014 January | 34 | 13 | 47 |
| 2013 December | 38 | 16 | 54 |
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