Palatal Petechiae in the Absence of Group A Streptococcus in Pediatric Patients with Acute-Onset Neuropsychiatric Deterioration: A Cohort Study

Palatal petechiae are 95% specific for streptococcal pharyngitis. Despite this, and despite prior research demonstrating that Group A Streptococcus (GAS) is a common antecedent to pediatric acute-onset neuropsychiatric syndrome (PANS) episodes, we anecdotally observed a low rate of documented GAS in...

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Bibliographic Details
Published in:	Journal of child and adolescent psychopharmacology Vol. 27; no. 7; p. 660
Main Authors:	Mahony, Talia, Sidell, Douglas, Gans, Hayley, Cooperstock, Michael, Brown, Kayla, Cheung, Joanne M, Farhadian, Bahare, Gustafson, Melissa, Thienemann, Margo, Frankovich, Jennifer
Format:	Journal Article
Language:	English
Published:	United States 01-09-2017
Subjects:	Acute Disease Adolescent Autoimmune Diseases - diagnosis Autoimmune Diseases - epidemiology Autoimmune Diseases - psychology Child Child Behavior Disorders - diagnosis Child Behavior Disorders - epidemiology Child Behavior Disorders - psychology Child, Preschool Cohort Studies Female Humans Male Neurodevelopmental Disorders - diagnosis Neurodevelopmental Disorders - epidemiology Neurodevelopmental Disorders - psychology Palate - microbiology Palate - pathology Purpura - diagnosis Purpura - epidemiology Purpura - psychology Retrospective Studies Streptococcal Infections - diagnosis Streptococcal Infections - epidemiology Streptococcal Infections - psychology Streptococcus pyogenes - isolation & purification group A streptococcus infection PANS petechiae youth child
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Summary:	Palatal petechiae are 95% specific for streptococcal pharyngitis. Despite this, and despite prior research demonstrating that Group A Streptococcus (GAS) is a common antecedent to pediatric acute-onset neuropsychiatric syndrome (PANS) episodes, we anecdotally observed a low rate of documented GAS in patients with PANS and palatal petechiae. This retrospective chart review was conducted to formally report the rate of palatal petechiae and concurrent GAS in a cohort of patients with PANS and investigate other etiologic factors. The clinical notes of 112 patients seen at the Stanford PANS Clinic who met PANS research criteria were reviewed for mention of palatal petechiae. The medical records of patients who demonstrated palatal petechiae on physical examination were reviewed for signs of infection, a clinical history of trauma, and laboratory results that could indicate other causes of petechiae. Twenty-three patients had documented palatal petechiae on physical examination (ages 5-16, 13/23 [57%] male). Fifteen patients had a rapid GAS test and GAS culture in the Stanford PANS clinic, all with negative results. Evidence of recent GAS infection was found in 8/23 (32%) patients (elevated GAS titers [n = 6] or documentation of a positive rapid GAS test at another facility [n = 2]), one of whom also had potential herpes simplex virus (HSV) infection. One patient had potential HSV infection and recent palatal trauma. No patients had thrombocytopenia. 14/23 (61%) of patients with palatal petechiae had no discernable cause of petechiae. 10/19 (53%) of patients had antihistone antibodies. Despite the established relationship between palatal petechiae and GAS, no patient with palatal petechiae in our clinic tested positive for GAS and only 32% had evidence of recent GAS. Most did not have an identifiable cause for the palatal lesions. This finding suggests the potential for alternative causes of palatal petechiae or undetectable GAS in our patient population. The high prevalence of palatal petechiae without GAS infection suggests that the pathogenesis of PANS is multifactorial and may involve disruption or inflammation of the microvasculature. Additional research is needed to further elucidate these findings.
ISSN:	1557-8992
DOI:	10.1089/cap.2016.0153