CLINICAL PRACTICES , TREATMENT MODALITIES AND GENETIC

VARIATIONS OF PANDAS/PANS PATIENTS IN SOUTHERN TURKEY

Assoc Prof Dr Gonca CELIK

Cukurova University Child and Adolescent Psychiatry Department, Adana, TURKEY

Common Threads Autoimmune Neuropsychiatric Disorders New York, 9-10 March 2018

PRESENTATION TOPICS– Clinical / Case Studies in Cukurova University, TURKEY

– Familial History and PANDAS

– Vitamin D and PANDAS

– PANDAS/PANS and Genetic Susceptibility

– Future hypothesis may be interest about genetics and certain autoimmune neuropsychiatric diseases.

• Autoimmunity and its effects on neuropsychiatric disorders are still unknown efficiently yet.

• Clinical variety, • Familial autoimmunity • Severity of symptoms could reflect on complex

interactions of immune system, environmental factors, genetic and ethnicity.

• We reviewed patients in field of research and clinical experiences admitted to our PANDAS/ PANS outpatient clinic in the southern region of Turkey.

• The terminology has been evolving from PITANDS to PANS in order to explain widely symptomatology and etiology more clearly

• PITANDS PANDAS PANS

Chang et al. Consensus Statement 2015

Familial Collagen Tissue/Autoimmune Disease and Serum Levels of Antinuclear Antibodies in PANDAS OCD Patients

• The aim of this study was to investigate the frequency of familial history of collagen tissue disease and antinuclear antibody (ANA) positivity in cases with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) related to childhood Obsessive Compulsive Disorder.

• Method: To determine psychiatric diagnoses, Schedule for Affective Disorders and Schizophrenia for School-Age Children--Present and Lifetime Turkish Version (KSADS-PL) was administered to the patients followed up with the diagnosis OCD.

• Serum levels of Anti Streptolysin O (ASO), C Reactive Protein (CRP) and Anti nuclear Antibody (ANA) were screened.

Familial Collagen Tissue/Autoimmune Disease and Serum Levels of Antinuclear Antibodies in PANDAS OCD Patients

• N= 91 OCD patients. • N= 52 patients (57,1%) were diagnosed with PANDAS, • N=19 (20.9%) were diagnosed with non- PANDAS • N=20 (22%) were diagnosed with PANDAS-variant. • History of familial CTD was found in 34 (37.4%) of the

cases. • Among these,18 (52,9%) were first degree relatives

while 16 (47,1%) were second degree relatives. • ANA positivity was most common in the PANDAS

group, present in N=15 patients (28,8%) indicating a statistical significance at p=.90.

Familial Collagen Tissue/Autoimmune Disease and Serum Levels of Antinuclear Antibodies in PANDAS OCD Patients

Familial collagen tissue disorder/autoimmune disease history n=34 (%37.4) N=18 (%52.9) was first degree relative (mother, father...etc) N= 16 (%47.1) was second-degree relative (aunt, grandmother, grandfather...) These are respectively Rheumatoid Arthritis (n:7, %20.5) was most common Vitiligo (n:6, %17.6), Non Spesificied Collagen Tissue Disease (n:6, %17.6), Psoriasis (n:5, %14.7), Behçet Disease (n:3, %8.8), Anycilozan Spondilitis (n:2, %5.8), Celiac disease (n:2, %5.8), Systemic Lupus Erhytematosus (n:1, %2.9) Multiple Sclerosis (n:1, %2.9) Familial Mediterrenean Fever-FMF (n:1, %2.9)

Familial Autoimmunity

No Familial Autoimmunity

GenderGirl 14 (41,2) 33(57,9) 0,123

Boy 20(58,8) 24 (42,1)Symptom Onset<11 0,093>11Medical History

Tonsillectomy 17 (50) 17 (29,8) 0,054Penicillin Prophylaxis

25(73,5) 27 (47,4) 0,015

Family HistoryARF 31(91,2) 44 (77,2) 0,090

OCD/Tics 31 (91,2) 47(82,5) 0,250

OCD PANDAS NON PANDAS

PANDAS VARIANT

P

Gender N % N

Female 47 (51) 20 (38,5) 14 (73,6) 13 (65)0,013

Male 44 (49) 32 (91,5) 5 (26,3) 7 (35)

Age of onset

<11 83 (91,2) 50(96) 15 (79) 18(90) 0,075

>11 8 (8,8) 2(4) 4 (21) 2(10)

Clinical FeaturesPenicillin Prophylaxis

52(51,1) 40 (76,9) 3 815,8) 9(45) 0,001

Tonsillectomy 34(37,4) 29 (55,7) 5(25) 0,001

ComorbidityADHD 67 (73,6) 41 (78,8) 9(47,4) 17(85) 0,012

Tourette 26(28,5) 17(32,7) 2(10,5) 7(35) 0,144

Anxiety Disorders 42(46,1) 22(42,3) 11 (57,9) 9 (45) 0,503

OCD PANDAS NON PANDAS

PANDAS VARIANT

P

FamilialHistory

ARF/RC 75(82,4) 50 (96,1) 9(47,4) 16(80) 0,0001

OCD/TIC 78 (85,7) 48(92,3) 13(68,4) 17(85) 0,039

CTD 34(37,4) 22(42,3) 5(26,3) 7(35) 0,455

Laboratory

ANA positivity

19 (20,9) 15(28,8) 2(10,5) 2(10) 0,090

Poster Presentation, ESCAP 2017 Geneva

Vitamin D and Immune System

Recently, “autoimmune ecology” as a new concept claims that environmental factors may be m o r e i m p o r t a n t r a t h e r t h a n g e n e t i c susceptibilities. (Anaya et al 2016)

Smoking, vaccines, coffee, sex, hormones, vitamin D, microbiata, silica…etc.

Vitamin D and Immune System• Vitamin D is a neurosteroid, antienflamatuar ,

immunomodulator and neuroprotective molecule. (Groves 2014) • The reported biological effects of 1,25(OH)2D3 in the nervous

system include the biosynthesis of neurotrophic factors and neurotransmitters synthesis. (Garcion 2002)

• Animal studies supported that prenatal vitamin D deficiency is related decrease of hippocampal neurogenesis.

• Autoimmune encephalomyelitis symptoms decrease Myelin Oligodendrosit protein and Vitamin D combination (Minicucci 2015)

• During development, Vitamin D deficiency is related apoptosis based gene expression. (Ko 2014)

VITAMIN D and Immune System

• Autism

• Schizophrenia

• Depression (Especially in elder)

• Hospitalized psychiatric patients

DSM V Obsessive Compulsive Disorder and Related Disorders

• Obsessive Compulsive Disorders • Body Dysmorphic Disorder • Trichotillomania • Skin Picking • Substance/ medication induced Obsessive Compulsive Disorder and

Related Disorders • Obsessive Compulsive Disorder and Related Disorders due to another medical condition • Other specified Obsessive Compulsive Disorder and Related

Disorders • Unspecified Obsessive Compulsive Disorder and Related Disorders (e.g. Body focused repetetive behaviors, obsessional jealousy)

SUBJECTS n=58 children and adolescent patients girl= n=28, %48,3 / boy n=30, %51,7 • N=35 Obsessive Compulsive Disorder • N=6 TTM Trichotillomania • N=5 Body Dysmorphic Disorder (BDD) • N=3 Hoarding Disorder • N=1 BDB • N=4 OCD comorbid TTM • N=2 OCD comorbid Skin Picking • N=1 OCD comorbid BDD • N=1 OCD comorbid SP and TTM

(n) (%)

Prenatal/Natal history Stres 36 64,3 Smoking 7 12,5 Prenatal problem 14 25 Natal complications 5 8,8Medical Conditions

Recurrent Infection 34 59,6 Tonsillectomy 10 17,2 Adenoidektomi 13 22,4 Ab profphylaxy 6 10,3 Allergy 20 34,5 Autoimmunity 6 10,3Familial History Familial OCD 43 74,1

Recurrent Infection 33 56,8 Tonsillectomy 22 37,9 Adenoidectomy 22 37,9 Ab Prophylaxy 9 15,5 Allergy 35 60,3 Acute Rheumatic Fever 8 13,8 Autoimmunity 27 46,6

IgA(µg/ml) ASO(IU/ml) CRP(mg/dl)

Familial OCD

Yes 2379,3±1135,5 196,5±203,4 0,2±0,2

No 2663,5±1678,7 263,3±330,8 0,1±0,1

Control 2945,4±1299,0 71,9±52,8 0,2±0,1

p1 0,467 0,360 0,258

p2 0,017 0,000 0,150

p3 0,069 0,000 0,240

P1: IgA levels differences between patients with Familial Ocd history and non familial history P2: IgA levels differences between patients with Familial Ocd history and control subjects P3: IgA levels differences in three gropus.

IgA(µg/ml) ASO(IU/ml) CRP(mg/dl)

PANDAS 2423,1±1316,6 336,2±107,1 0,29±0,1

N-PANDAS 2478,6±1283,0 107,1±67,2 0,19±0,1

Control 2945,4±1299,0 71,9±52,8 0,21±0,1

P1 0,872 0,000 0,1

P2 0,074 0,000 0,047

P3 0,089 0,000 0,086

p1: PANDAS and N-PANDAS, p2: PANDAS and control , p3: PANDAS , N-PANDAS and control.

FAMILIAL AUTOIMMUNITY

Yes No pAge 11,7±3,5 13,7±2,8 0,022

Symptom Onset Age 8,8±4,1 11,3±3,2 0,016

Clinical FeaturesInfection triggered symptoms

13(48,1) 5(17,9) 0,017

Sensorial Hypersensitivity

20(74,1) 15(51,7) 0,084

Tics 9(33,3) 4(13,3 0,072 Familial History Recurrent Infection 20(74,1) 11(39,3) 0,009

Tonsillectomy 14(51,9) 8(25,8) 0,041 ARF 7(25,9) 1(3,2) 0,012 OCD 25(92,6) 16 (55,2) 0,002

IgA(µg/ml) ASO(IU/ml) CRP(mg/dl)

Autoimmune Disease Yes No Control p1 p2 p3 Familial Autoimmunity Yes No Control p4 p5 P6

2454,1±1502,4 2452±1277,3

2967,1±1357,3 0,998 0,378 0,091

2054,6±1083,8 2799,6±1365,6 2967,1±1357,3

0,027 0,002 0,008

371,4±470,9 195,5±200,1 71,9±52,8

0,091 0,000 0,000

219±1±231,5 209,1±253,3 71,9±52,8

0,876 0,000 0,000

0,2±0,1 0,2±0,2 0,2±0,1 0,783 0,906 0,579

0,2±0,1 0,2±0,2 0,2±0,1 0,712 0,596 0,554

IgA (µg/ml) ASO(IU/ml) CRP(mg/dl)

OCD Yes 2549,0±1255,1 217,4±259,9 0,2±0,2

No 2177,0±1383,4 203,1±185,1 0,1±0,0

Control 2945,4±1299,0 71,9±52,8 0,2±0,1

p1 0,340 0,845 0,164

p2 0,104 0,000 0,126

p3 0,057 0,000 0,149

OCD spectrum

Yes 2239,0±1373,0 198,7±185,1 0,1±0,0

No 2593,3±1228 223,6±274,2 0,2±0,2

Control 2945,4±1299,0 71,9±52,8 0,2±0,1

p4 0,309 0,705 0,143

p5 0,025 0,000 0,534

p6 0,054 0,000 0,128

PERIODIC FEVERSPeriodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis (PFAPA) non-monogenic

Autosomal Recessive

Familial Mediterranean Fever- (FMF)-MEFV1 mutation Hyper Immune Globulin D Syndrome- (HIDS) MEVK mutation

Autosomal Dominant

Cryopyrin-associated periodic syndrome (CAPS) – NLRF3 mutation Tumor Necrosis Factor Receptor-associated Periodic Fever Syndrome (TRAPS)- TNFRSF1A mutation

Paediatric Rheumatology International Trials Organisation (PRINTO) and Eurofever Project ; Sag et.al. Curr Rheumatol Rep (2017) 19: 41

HIDS-PERIODIC FEVER

• He has comorbid ADHD and OCD . During fever attack his motor and vocal tics has increased.

• E’s mother, a 38-year-old had OCD, and a history of acute rheumatic fever (ARF) complicated by rheumatic heart disease (RHD).

• The patient’s 14-year-old sister had been treated for OCD

• E’s maternal grandmother also had 10 years history of ARF and rheumatoid arthritis (RA).

• Additionally, his maternal aunt had a 2 years history of RA.

HIDS-PERIODIC FEVERBecause of periodic fever attacks and for exclusion of any periodic fever syndromes, E was referred to our rheumatology immunology department. His serum anti-Streptolysin O (ASO) titer was 539 IU/L (prior to tonsillectomy) and 226 IU/L (after the tonsillectomy). During an attack, white blood cell count (WBC) was 11.000mm–3; erythrocyte sedimentation rate (ESR) was 27 mm/h; and IgD was 72.5mg/L (radial immunodiffusion [RID], n 5–50), IgA was 107 mg/ dL. No mutation was found in the Mediterranean fever gene (MEFV) (DNA sequencing for exon 2 and exon 10); MVK gene homozygote c.769–38 C > T mutation was determined. (The exonic regions and exon–intron junction sites of these genes were amplified by polymerase chain reaction [PCR]/sequence-based typing technique using specific primers). Pharyngeal culture was negative for bacterial growth.

IMMUNO-GENETIC STUDIES

GENETIC SUSCEPTIBILITY ?• Familial ancestral continuity • Environmental toxins vs. growing

brain Specific Ethnic background • Evolution may cause non adaptive

immunity ? • Geographic conditions/certain

genetic disease (sun light, tropic disease malaria?/thalassemia ?)

• Being a carrier of any genetic mutation does not mean that you will have a disease !!

• Epigenetics and cell biology may be future research interest area in autoimmune neuropsychiatric disease

Immune Genetic Studies : Mannose-binding lectin (MBL)

• The Mannose-binding lectin (MBL), is an important protein of the humoral innate immune system. It provides first-line defence and also activates the complement system (Dommet 2006)

• Patients with MBL deficiency exhibit an increased vulnerability to both infectious diseases (Streptococcus, Lyme, Some Viral Infections) and autoimmune diseases, such as rheumatoid arthritis, Systemic Lupus Erythematosus. (Schuijt 2011,Koch 2001, Dolman 2008)

• Estimated prevalance MBL gen polymorphism is 25-30% (caucasian).

IMMUNE GENETIC STUDIES and MBL

• MBL, binds to microorganisms polysaccharides and activates the complement system via opsonization process… sometimes called as Acute Phase Reactan? (Keizeret al 2014)

• Brouwer et al reported MBL-substitution (Phase I and II) study in pediatric oncology patients with chemotherapy-induced neutropenia. (Brouwer 2009)

• They found increasing MBL/MASP (mannose-associated serine protease 1)-mediated C3 and C4 activation and opsonophagocytosis although suboptimal changing serum MBL levels.

IMMUNE GENETIC STUDIES and MBL

• The three most common polymorphisms of the MBL2 gene at codon 52 (arginine to cysteine; D) ; codon 54 (glycine to aspartic acid; B); codon 57 (glycine to glutamic acid C) are located in exon 1 that cause significant reduction of serum MBL level (Garred 2006)

Mannose-Binding Lectin2 gene polymorphism in PANDAS patients

• Methods: The study included 102 pediatric OCD patients (59 [57.8%] PANDAS, 20 [19.6%] non-PANDAS, and 23 [22.5%] PANDAS-Variant) and 60 healthy controls. Polymorphisms at codon 52, 54 and 57 of the MBL2 gene were investigated.

• Results: Codon 54 polymorphism and any variant of MBL2 gene were significantly more frequent in the OCD group than in the control group (OR=2.97, 95% CI: 1.26-6.97; and OR=2.66, 95% CI: 1.32-5.38, respectively).

• According to regression analysis, the presence of any variant of MBL2 gene was found in 14.50-fold increased frequency in the PANDAS subgroup compared with the non-PANDAS subgroup (95% CI: 2.49-84.19).

• Conclusions: Our findings support an association between MBL2 genotypes and pediatric OCD, particularly PANDAS-OCD.

HYPOTHESIS ABOUT GENETIC SUSCEPTABILITY

• Especially autoimmune conditions may be more common in certain geographic area, Mediterranean region.

• Specific genetic – ethnic background may be related to high prevalence with autoimmune disease.

HYPOTHESIS ABOUT GENETIC SUSCEPTABILITY

• Thalassemia is a most common hematologic disease disrupted globulin production autosomal recessive inherited in certain geographical region .

• Genetic prevalence is more common in especially in Mediterranean area compared with other regions of world.

• However silence carrier state and its clinical importance are not well known.

HYPOTHESIS ABOUT GENETIC SUSCEPTABILITY

• The β-thalassemia carrier trait is reported as 1 to 20 % . – Cyprus 14% – Sardinya 10% – Turkey 2,1% (Some regions its up to 13 %, e.g.

Adana city) • The frequencies for the milder forms of a-

thalassemia are 10 to 20% in parts of sub- Saharan Africa. (Williams 2012)

HYPOTHESIS ABOUT GENETIC SUSCEPTABILITY

• An possible association between autoimmunity and thalassemia trait has been stated by Altinöz et al. 2012

• Thalassemia-heterozygote mutations may change the hemorphins molecule which associated with suppression of inflammation and neutrophil migration.

• Thalassemia heterozygotes and /or carrier state might prone to autoimmunity for hemorphin supression.

• Malaria Vulnerability Malaria Resistance

Hemoglobinopathies G6PD deficiency Thalassemia (alpha / beta/ carrier state) Sickle cell

Kwiatskovski Am. J. Hum. Genet 77:171–192, 2005

EPIGENETIC

SUMMARY

EPIGENETIC?

Immune Genetic susceptibility Abrupt onset incidentally Familial Autoimmunity Thalassemia? Neuropsychiatric SYMPTOMS Periodic Fevers Immune Abnormality ONGOING IMMUN DEVELOPMENT

Environmental factors • Vitamin D deficiency • Preterm birth • H1N1 vaccine ?

• Stress • Cortisol

ONGOING BRAIN DEVELOPMENT

PANDAS-PARENTS AWARENESS DAY

2015 Cukurova University

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