Acute-onset neuropsychiatric syndrome may present as complication of COVID-19 infection in kids

Neurological and psychiatric disorders in patients with a COVID-19 infection have been reported, such as cerebral ischaemic stroke, intracerebral haemorrhages, encephalopathy, and cerebral vasculitis and Gullian-Barre syndrome. Pediatric acute-onset neuropsychiatric syndrome (PANS) belongs to a group of neurological disorders suspected to have a postinfectious origin. Autoimmune, and neuro-inflammatory events are the main mechanisms of PANS.

PANS presents with a sudden onset of obsessive-compulsive disorder (OCD) or a severely restricted food intake, and concurrent neuropsychiatric symptoms and motor dysfunction.

Piero Pavone and his team reported two rare cases highlighting the association of pediatric acute-onset neuropsychiatric syndrome with COVID-19 infection.

CASE 1:

A 12 year old boy was referred with abrupt onset of psychiatric disturbaces. Prior to this he was tested positive for SARS-CoV2 RTPCR at school as he had exposure to his classmates but he was asymptomatic initially. Parents denied any past history of psychiatric or movement disturbances.

After approximately 2 weeks, the boy presented a sudden onset of psychiatric signs, such as a fear of catching infections and touching handles with a severe drive to wash his hands very often and accurately. Parents informed that he had facial motor tics, emotional lability and also showed reduced appetite. A general physical examination showed that he was physically healthy, including cardiac and neurological examinations.

Basic laboratory tests were reported normal with a negative ASO titres and a negative anti-DNAase B antibodies. He was tested positive for anti-basal ganglia antibodies with a titre of 1:200. Autoimmunity panel against certain specific antibodies was negative. At admission to hospital he was tested positive for SARS-CoV2 (nasal swab,RTPCR), which is 14 days after first positive report. EEG and MRI brain were unremarkable for any focal lesion. Upon evaluation by the Children's Yale-Brown Obsessive Compulsive Scale score was 22(score more than 16 is indicative of OCD). Psychological intervention was started and child was under followup.

After 2 months of follow-up, his distress for hand cleanliness persisted along with selective eating. Motor tics also persisted but were not constantly present. A swab test for COVID-19 was negative. The mother of the patient still had complaints about the boy's lack of attention and irregular writing.

CASE 2:

A 13-year old boy was admitted with sudden onset of psychiatric symptoms-such as a compulsive disorder characterised by using only a tablespoon during his meals and arranging the tip of his shoes in parallel before going to sleep. Parents denied noticing similar symptoms previously. His past history was notable for positive SARS-CoV2 infection and was symptomatic (fever,cough,GI disturbances). At the physical and psychological examination, he had a facial motor tic, guttural vocal tics, hyperactivity, aggressiveness, irritability and inattentiveness.

All laboratory tests had either negative or normal results except for anti-basal ganglia antibodies, which had a titre of 1:100. EEG and MRI brain were normal. He was scored 28 on the Children's Yale-Brown Obsessive Compulsive Scale. Psyhcological treatment was initiated and child was monitored frequently at OPD.

At follow up after a month, parents reported that he continued to be aggressive and irritable with no clinical modification.

Therefore, it is possible that, in these cases, the SARS-CoV-2 virus has caused PANS, although this cannot be confirmed. Hence from the two young adolescents, a possible new-onset PANS has been reported suggesting a temporal correlation between SARS-CoV2 and PANS.

Authors conclude-"In the current ongoing pandemic, SARS-CoV-2 needs to be acknowledged in the differential diagnosis of PANS."

Source: Pavone P, Ceccarelli M, Marino S, Caruso D, Falsaperla R, Berretta M, Rullo EV, Nunnari G. SARS-CoV-2 related paediatric acute-onset neuropsychiatric syndrome. Lancet Child Adolesc Health. 2021 Jun;5(6):e19-e21. doi: 10.1016/S2352-4642(21)00135-8.