PANDAS – A Carcinosin Case

PANDAS is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. This diagnosis is used to describe a set of children who have a rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorders such as Tourette syndrome, following group A beta-hemolytic streptococcal infections such as “strep throat” and scarlet fever. The proposed link between infection and these disorders is an autoimmune reaction, where antibodies produced by the infection interfere with neuronal cells

The abnormal behaviours come on suddenly and are overt and easily recognized. The child becomes hyperactive, moody and can begin rapid blinking of the eyes. She can also become very particular about the way she does certain things.

More recently, PANDAS has been associated with a wider range of related behaviours. Affected children can have any combination of the following symptoms:

• Cognitive inflexibility, difficult to reason with, as if stuck on an idea
• Obsessive, repetitive, compulsive, argumentative behaviours
• TICS (repetitive vocalizations or body movements)
• Tourette Syndrome
• Attention deficits and oppositional /defiant behaviours.

Generally after several weeks, all or most of the symptoms go away, but often return if the child develops another Strep throat infection (detected or undetected). The symptoms can follow even a small illness. The current treatment is daily prophylactic antibiotic therapy which has variable results.

Typically, a child with undiagnosed PANDAS may be taken to the Psychologist and/or Paediatrician for treatment of an onset or exacerbation of ADHD symptoms, oppositional behaviours or OCD. Stimulant or anti-depressant medication may be prescribed and/or a behavioural intervention or counselling initiated. As the infection passes and the strep antibodies reduce, the symptoms gradually subside and parents and clinicians believe that the intervention was successful. However, when there is another strep infection, the symptoms return and the process is repeated. It is theorized that the brain is being continuously damaged by the repeated attacks by streptococcus antibodies, and after each attack the recovery of damaged brain tissues may not be complete. Eventually the child may develop a chronic psychiatric disorder

THE CASE

Adelle is a third grade student at a small private school that places an emphasis on the arts. She has the lead part in a musical play based on The Phantom Tollbooth. She has to have confidence to perform and has many friends in school. She has a few friends in the 5^th and 6^th grade and really prefers to play with older children. At home she spends time reading and playing with her two older cats.

The pregnancy was normal, but by 30 weeks the baby was in the breech position. At 37 weeks the obstetrician was able to do a successful external version and she was born by vaginal delivery.

As a baby Adelle had trouble nursing at first, and this was worsened as her mother suffered several bouts of mild mastitis and cracked nipples. From the very beginning she was a poor sleeper. She cried at night and was difficult to settle and she woke frequently during the night. From early infancy she experienced a burst of energy right before bed time.

Even today, at age 8, Adelle does not sleep well. It is difficult for her to fall asleep and, although she goes to bed at 9pm her mind gets revved up in the evening and it takes an additional hour to get to sleep. What kind of thoughts go through her mind before she falls asleep? She thinks about which projects are due for turning in on the next day. In the middle of the night Adelle wakes up and gets into bed with her parents. She has never slept through the night.

In the first year of life Adelle had many high fevers with temperatures in the range of 104 degrees. When she began preschool she got sick more frequently with viruses and fevers. One time she was diagnosed with an ear infection and was treated with antibiotics. At age four she became sick with a fever of 105 degrees and developed pneumonia. It took a few courses of antibiotics to bring this illness under control.

Adelle was an independent toddler who began to speak at an early age. She was strong willed and easily developed relationships with adults as well as having friends of her own age. Early on Adelle demonstrated a love of animals. Even as a toddler she was very gentle with dogs and cats and always knew when the animals were hungry and thirsty or in need of comfort. She also likes horses and horseback riding. Adelle is a cautious child, who does not like speed or heights. There is a famous Boardwalk amusement park in Santa Cruz but Adelle will not go on any of the rides at the park. She also does not like to be at the park if there are crowds. She will not sleep at any of her friends homes and has to be home at night. She worked hard to overcome the fear of taking off in a plane.

Adelle has a nervous stomach and will have stomach pain if she is stressed. Interestingly she has absolutely no stage fright and can go on stage without a single “butterfly”

Migraine headaches began in kindergarten. There is pain in the head and often it is accompanied by stomach pain. With the headache she becomes confused. Her mother describes it as a kind of “fit” where her behavior changes and she is unable to respond in her normal way. Often she will vomit and then feel better. Taking a hot shower makes her feel far better when she has a headache. She feels it opens her pores and seems to lessen her headache. Her mother theorizes that she is sensitive to high fructose corn syrup. She does not like the sun but loves the rain. She likes the beach but far prefers the deep shade of trees.

Adelle has a case of Molluscum contagiosum. It is a severe case and the lesions were all over her body. Prior to that she had eczema which was treated with cortisone cream.

Adelle does not like change. She will become furious if her mother cleans her room or makes her bed without first telling her. Adelle cannot sleep well in a hotel room. She says that it just does not feel like home. “It is not what I am used to and I don’t know where things are”. She likes her room to be her sanctuary. She will throw her clothes on the floor, but the shelves are maintained in a very specific way. Everything in her room needs its own place and she gets comfort from the stability of her room. When she has friends come over to play, they are not allowed to come into her room. “They make a mess of my special place.”

Before being diagnosed with PANDAS Adelle had become extremely moody and sensitive to criticism. Her previous tendency to perfectionism was greatly amplified and when stressed, she became flustered and began to rapidly blink her eyes in an involuntary manner. She is extremely sensitive and feels her mother is being mean. She is obstinate and also anxious and she worries about many things and can feel sad with no real reason. When she is feeling sensitive she wants to be alone. She will sit alone in her room and chew her fingertips. Even though she can isolate herself when feeling moody, Adelle cannot be in the house alone. She cannot fall asleep without one of her parents sitting with her until she is fully asleep.

Adelle is sensitive to the feel of fabrics and cannot wear regular stiff jeans. Her feet often feel “too dry” and she has to wet her feet before putting on her socks.

RUBRICS

An example of rubrics associated with this child include:

SLEEP; SLEEPLESSNESS; children, in

FEVER, HEAT; RECURRENT, history of, in children

SKIN; ERUPTIONS; eczema; children, in

MIND; READING; desire for

MIND; PRECOCITY

MIND; OBSTINATE, headstrong

GENERALITIES; AIR; seashore air; amel.

MIND; ANXIETY; stomach; in

MIND; FEAR; crowd; in a

MIND; SYMPATHETIC,

MIND; FASTIDIOUS MIND; LOVE; animals, for

MIND; SENSITIVE, oversensitive; reprimands, criticism, reproaches, to MIND; BITING; fingers; tips of

MIND; COMPANY; aversion to, agg.

MIND; FEAR; high places

Prescription Carcinosinum 200C

Follow-up

6-20-08

A positive change was noted 48 hours after taking the remedy. “It is as if a cloud lifted and the feeling of lightness has been sustained for all of these weeks”. Her room is still her sanctuary but she is fine with changes in the home such as a change in the position of furniture. Going to sleep is much easier. She does have to read certain books in a very specific order before going to sleep. The end of school was a triumph, with Adelle having great success as the lead in the school play. Her stomach gets sensitive about twice a week, down from complaints daily. She has not had any headaches since taking the remedy. If she scratches the molluscum, many more will appear in the same area. Her feet no longer feel “too dry.”

Adelle got a flu virus with a high fever of 104 degrees. She lost her appetite for four days and felt sick and dizzy. After the illness she got a rash over all of her body that lasted for three days. This is the first time in three years that she had and illness and did not manifest a change in behavior suggestive of PANDAS. Normally she has had a PANDA reaction after each cold or small illness.

Plan: wait

Follow-up

9/20/08

Adelle seems happier, less sensitive and less moody and is not exhibiting obsessive symptoms of tics such as eye blinking.

Adelle is able to sleep better and falls asleep more easily. She still tends to want to stay up late. She decided to try and sleep at a friend’s house but called in the evening and asked her parents to pick her up. However, she is planning to go on a camping trip with her class at school and is looking forward to it.

She is still having lots of stomach aches and does not feel well right after having her lunch at school. She has not had a headache since taking the remedy (four months). The Molluscum are almost completely gone. On the first day of a return to school Adelle woke with a cold and sore throat. She felt this way for four days but only missed two days of school. With the cold there was no return of PANDAS symptoms. This is the first time in three years that she had and illness and did not manifest a change in behavior. Her mood remained calm and consistent and she is rarely chewing her fingers or nails.

Adelle is a bit more flexible in general and is more accepting of change. She still does not have friends come into her room and is protective o the space because she built a sort of structure in the middle of the room and “I have my stuff organized in a special way.”

She actually began to change a few things and hung something new on the wall. Her feet are more comfortable in shoes and she rarely has to wet the feet to overcome the feeling of dryness.

Plan: wait

Follow-up

12/12/08

Wonderful improvement. No PANDA reactions seen since the remedy. No longer has stomachaches or headaches. All of the Moluscum are gone. Adelle goes to sleep easily and has friends sleep over in her room. She is still resistant to socks and has some sensitivity to fabrics. Transitions, changes and new environments are taken in stride. The atmosphere in the house is much easier and Adelle is very communicative and not at all moody. No illnesses, no symptoms of PANDAS

Plan: Wait

Conclusion

This case illustrates the use of a well known homeopathic remedy in a condition that is newly defined and thus not covered in our homeopathic repertories. In such a case we cannot rely on material medica and also it is better not to include symptoms that pertain to the clinical condition, such as compulsive disorders or sensitivity to clothing etc. Carcinosin deeply touched the case and two years after the initial remedy Adelle continues to enjoy good health and is free from symptoms of PANDAS.

The prescription was Carcinosin 200C. The potency was conservative because of the history of eczema and the relative fragility of the child at the time of the first visit. If, during the future course of this case, the Carcinosin 200C fails to act I would raise the potency to 1M. At this point, over two years after the initial case, Carcinosin 200C is still the prescription.