Case history
Case history #1
A 4-year-old girl presents with new-onset severe obsessive-compulsive disorder (OCD), separation anxiety, generalised anxiety, and behavioural regression (i.e., becoming clingy, using baby talk, wanting to be breastfed) overnight. On examination, she has a red pharynx, enlarged tonsils, and palatal petechiae. She tests positive for group A streptococcus (GAS). She is given a 10-day course of amoxicillin, as well as ibuprofen when required for 3 weeks for acute pharyngitis, with prompt improvements of OCD and anxiety symptoms and returns to baseline. Ibuprofen is continued for 6 weeks then discontinued. Around 18 months later, she has another sudden overnight escalation in OCD, anxiety, irritability, and behaviour regression after coming home from a sleepover with her best friend. Her best friend tests positive for GAS pharyngitis on rapid antigen detection test that afternoon. Three days later, she presents with palatal petechiae but with a negative streptococcal culture. She is given the same course as previously of amoxicillin and ibuprofen and returns to a good baseline, but with mild ongoing OCD symptoms, which respond to cognitive behavioural therapy (CBT). She has no streptococcal exposures or severe relapses during the following school year. Mild escalations in OCD, anxiety, and behaviour issues following a virus infection are short-lived and she responds well to CBT and brief courses of ibuprofen.
Case history #2
An 8-year-old boy presents with sudden-onset (minimal to maximum symptoms over 48 hours) of severe OCD, anxiety, motor tics, urinary frequency, episodic enuresis, and encopresis. He has a history of relapsing-remitting episodes of behaviour change, head jerking tic, anxiety, obsessive-compulsive tendencies, and encopresis. There is no history of GAS infection (although his mother says that GAS infection is going around school and among his peers during previous episodes). On examination, he appears tired (he is slumped in his chair) and anxious, with dark circles around his eyes. The neurological examination shows choreiform movements of fingers, weak grip and subtle milkmaid grip, overflow dystonia stress gait, truncal instability due to mild truncal hypotonia, arm weakness/fatigue (difficulty holding arms up for touch down sign and Rhomberg test), spooning of right hand during the Rhomberg test, and inability to perform a duck walk test due to joint pain and motor incoordination. There is no chorea. His patellar reflexes are 2+ bilaterally and not 'hung-up'. Glabellar tap is normal. The musculoskeletal examination shows multiple tender joints and entheseal insertion points. Ultrasound of joints reveals joint effusions and synovitis in fingers and toes (confirming arthritis) and signal changes/fluid at the Achilles insertion point. Laboratory findings include an increase in anti-streptolysin O (ASO) and anti-deoxyribonuclease B (ADB) titres with relapses. During his improved states and remission, ASO and ADB titres are at the lower end of the age-defined range and complements are higher and in the normal range. He has mild leukopenia and monocytosis. C-reactive protein and erythrocyte sedimentation rate are normal even when arthritis is active.
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