Obsessive-Compulsive Disorder , Tics , and Autoinflammatory Diseases : Beyond PANDAS Presenters :

Parents reported that since A. was diagnosed with mononucleosis at age 10, he had been experiencing recurrent episodes of low-grade fever, asthenia, arthralgia, headache, concentration difficulties, and abdominal pain. These episodes occurred every 1–2 months, lasted 2–3 weeks, and did not have an obvious trigger. During the episodes of illness, A. was so exhausted that he could not attend school or meet his friends, but he was able to resume his daily activities as soon as symptoms remitted. Since the beginning of the present condition, A. had been referred to a variety of specialists. After ruling out the most common medical conditions, A. was evaluated by a team of rheumatologists who diagnosed chronic fatigue syndrome. However, A.’s parents did not consider fatigue to be the main problem and made an appointment with an internist for a second opinion. Guided by gastrointestinal manifestations (abdominal pain occasionally accompanied by diarrhea and weight loss), the doctor ordered an endoscopy and serologic tests to screen for celiac disease. Results were negative, except for identification of villous atrophy and Periodic Acid-Schiff (PAS)-positive macrophages in the duodenal biopsy. With suspicion of Whipple disease, A. was started on trimethoprim/sulfamethoxazole and subsequently switched to doxycycline for leukopenia. After a 4-month trial with doxycycline, gastrointestinal symptoms persisted, so antibiotics were discontinued. Soon after A. was diagnosed with mononucleosis, he started exhibiting obsessive-compulsive symptoms. At that time, he needed the TV volume to be set at a specific number and avoided touching surfaces that were not completely clean. At age 14, obsessive-compulsive symptoms started impacting his daily life, so his parents made an appointment with a psychiatrist who diagnosed obsessive-compulsive disorder (OCD). Given A.’s difficulties engaging in a structured cognitive-behavioral therapy due to his medical condition, medication was initiated. A. was started on sertraline 50 mg once a day and gradually titrated to 100 mg bid. He tolerated the medication well, without any side effects. Obsessive-compulsive symptoms partially remitted and persisted during the following episodes of illness. In addition to obsessive-compulsive symptoms, A. also exhibited motor tics. Parents reported that A. developed the onset of tics at age 9, soon after the family returned home from living abroad for 1 year. A. recalled the return as a sad and stressful period in his life. Initially, A. developed eye and facial movements and gradually went on to have other tics involving his limbs. Parents reported that A. also used to sigh repeatedly. Retrospectively, this was probably his first vocal tic, but it was not recognized as such at the time. Motor tics persisted and increased during the following year, so A. was referred to a neurologist who diagnosed chronic motor tic disorder. At that time, no therapy was started as tics were not impacting A.’s functioning. By the age of 14, his tics increased and the psychiatrist started risperidone 0.5 mg bid. A.’s tics improved subsequently and by the time of the evaluation, A. was only exhibiting eye blinking. Despite the positive response to medication, his tics tended to worsen with fatigue, particularly during the episodes of illness, and eye movements were occasionally so intense that botulinum toxin injections were required. In addition to tic exacerbation, A. also reported concentration difficulties during the episodes of illness. A. did not show symptoms of attention-deficit/hyperactivity disorder, but he was started on short-acting methylphenidate during an episode of illness to help maintain academic performance. This medication had to be discontinued immediately due to an allergic reaction (orofacial edema). Given the episodic course of his psychiatric symptoms, A. was referred to a specialized clinic in tics and Tourette’s disorder for consultation regarding a question of PANDAS.