Addison's Disease Elucidating PANDAS

practice building Naturopathic Specialty Practice: Keys to NATUROPATHIC DOCTOR NEWS & REVIEW Making It Successful...... >>10 Darin Ingels, ND VOLUME 10 ISSUE 4 April 2014 | Autoimmune / Aller gy Medicine Sometimes specialty practices happen by accident. A case study and some tips help pave the way for Tolle Causam success. Tolle Causam Autoimmunity and the Gut: Elucidating PANDAS How Intestinal Inflammation Contributes to Autoimmune Disease...... >>12 Follow-Up Discussion of an Immune-Mediated Jenny Berg, ND, LAc Kelly Baker, ND, LAc Intestinal flora influences our immune system’s Mental Illness ability to differentiate self from non-self.

Steven Rondeau, ND, BCIA-EEG vis medicatrix naturae Allergy Elimination Technique: Simplified ANDAS is an acronym for “Pediatric Treatment of Difficult Cases...... >>15 PAutoimmune Neuropsychiatric Sheryl Wagner, ND Disorder Associated with Streptococcus.” A few case studies illustrate the surprisingly broad This condition, which was initially application of NAET with patients. identified by Sue Swedo, MD, and docere described in the American Journal of Autoimmune Infertility in Women: Psychiatry in 1998,1 is characterized by Part 2...... >>16 abrupt-onset obsessive-compulsive Fiona McCulloch, BSc, ND disorder (OCD) and/or other Intestinal support, autoimmune diet, and neuropsychiatric symptoms in a child. (See nutraceuticals help reverse a common cause of Table 1 for Swedo’s original diagnostic female infertility. criteria.) In my previous NDNR paper naturopathic news from 2010,2 I described the presentation, history and controversy surrounding this Association Spotlight: An Introduction newly identified syndrome. Since that to the ANRI and NORI...... >>20 time, several other groups have sought Colleen Huber, NMD to better redefine this condition, and the Dr Huber introduces ANRI & NORI, organizations committed to the advancement of research & acronym, PANS, or Pediatric Acute-Onset education on chronic disease. Neuropsychiatric Syndrome, was recently Continued on page 3 similar thought An Unusual Application...... >>21 Joseph Kellerstein, DC, ND Docere Zeroing in on unusual characteristics in a child leads to an unexpected remedy. botanical insights Addison’s Disease Opiate Addiction: Pathophysiology and Herbal Interventions...... >>22 A Naturopathic Approach Jillian Stansbury, ND Standard opiate maintenance therapies are problematic. Several herbs serve as safer options Amanda Hegnauer, ND 3. Secondary adrenocortical insufficiency: an autoimmune disease. Although all for addicts. This includes any disorder of the races and both sexes may be affected, drenal insufficiency, or hypofunction, hypothalamus and pituitary, such as certain causes of Addison’s disease, such The Expert report Amay be caused by either primary metastic cancer, infection, or infarction, as autoimmune adrenalitis, are much more Oral-Systemic Health Care...... >>24 adrenal disease (primary hypoadrenalism) which reduces the output of ACTH. common in whites, particularly women.3 Mark Swanson, ND or decreased stimulation of the adrenals In turn, this leads to hypoadrenalism, A large number of diseases may attack Dental hygiene is one of the easiest ways to prevent CVD, stroke, diabetes, and Alzheimer’s. owing to a deficiency of ACTH (secondary which has many similarities to the adrenal cortex, but more than 90% of hypoadrenalism). The patterns of Addison’s disease, although the all cases are attributable to autoimmune Nature Cure adrenocortical insufficiency can be hyperpigmentation characteristic of adrenalitis, tuberculosis, or metastatic Clinical Pearls considered under the following headings: primary Addison’s disease is absent, and cancers.3 Autoimmune adrenalitis accounts 3 Rebirth of the Body: 1. Primary acute adrenocortical aldosterone synthesis is near-normal. for 60-70% of cases of Addison’s, and may The Spring Cleanse...... >>26 insufficiency (adrenal crisis): This can occur as a sporadic or familial disorder. Sussanna Czeranko, ND, BBE be due to a variety of causes, such as loss Addison’s Disease In about half of these cases, the adrenal The theme of restoration and renewal from a spring of the cortex, idiopathic (autoimmune), Primary chronic adrenocortical gland is the sole target of an autoimmune cleanse is archetypically naturopathic. infection, acute hemorrhagic necrosis, and insufficiency (Addison’s disease) is reaction, but in the remainder of cases, metabolic failure in hormone production. an uncommon disorder resulting from other autoimmune disease, such as education In patients with chronic adrenocortical progressive destruction of the adrenal Hashimoto’s disease, pernicious anemia, The Emergence of the IANP: insufficiency, crisisa is precipitated by any cortex and, often, the adrenal medulla.3 type 1 diabetes mellitus, and idiopathic Right Time, Right Place...... >>28 form of stress that requires an immediate Because the condition arises from problems hypoparathyroidism, is also present. David J. Schleich, PhD increase in steroid output from glands within the adrenal gland, it is termed In autoimmunity, our adaptive (or An international association of naturopathic that are incapable of responding.1,2 “primary adrenal insufficiency,” and acquired) immune response (which professionals could provide a much-needed healthcare model for the international community. 2. Primary chronic adrenocortical because the damage is incurred by the insufficiency (Addison’s disease) body’s own immune system, it is termed Continued on page 8 Available online at ndnr.com

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Continued from top of page 1 introduced.3,4 Prior to PANS, the acronym Online Editorial Exclusives PITAND (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorder) Primum Non Practice had been suggested in the late 1990s after Nocere Building researchers hypothesized that there were more triggers beyond just Group A beta- The Wrong Target: The Fallacy of Online Booking: An Efficient hemolytic Streptococcus.5 In 2012, Using Hypoglycemic Agents in Way to Build Your Practice Diabetes K.C. Bateman, BSc, ND Dr Harvey Singer and his group proposed Richard K. Maurer, ND Online booking is a perfect way to share your schedule yet another description of acute-onset When the sole focus in diabetes is the lowering of glucose, between multiple locations and multiple users. behavioral symptoms in children: insulin resistance and CV risk can actually increase. Childhood Acute Neuropsychiatric Education Symptoms (CANS). These new acronyms Vis Medicatrix Message From the President: New Dean were all conceived to include all other Naturae Appointed at the University of Bridgeport abrupt-onset OCD or tic symptoms— not Holism in Autoimmune Disease: College of Naturopathic Medicine just those brought on by streptococcal Working in Harmony With the David M. Brady, ND, DC, CCN, DACBN infections but also including newly Healing Power of Nature Dr Marcia Prenguber brings a wealth of experience and .com Moshe Daniel Block, ND, HMC expertise to her new post as Dean. reported behaviors such as abrupt-onset Want more? Check online at ndnr.com restrictive eating and anorexia, as well A case study illustrates the importance of addressing the for these editorial exclusives, our mega root cause of illness in the mind. as verbal and motor tics. Additionally, updated calendar, and so much more. these broader definitions were proposed to include other infectious agents as triggers for the condition, such as viruses (eg, influenza and Varicella), Mycoplasma, and Borrelia, to name a few. This may TM be due in part to the approximately PRESCRIPT-ASSIST 190 peer-reviewed, indexed papers on PANDAS and its derivatives on PubMed, or to an explosion in cases seen in clinics worldwide. Whatever the reasons, the medical community today generally agrees that this is a real condition, despite the fact that that there is still no agreed- upon diagnostic criteria after more than a The clinically proven decade, nor a diagnostic code for insurance (in a double-blind, placebo-controlled trial) reimbursement. In addition to the lack of clear diagnostic criteria, there is still broad-spectrum uncertainty in the areas of prevention, (providing 29 strains of beneficial microorganisms) initial work-up, and standard-of-care protocols. In Table 2, the new proposed criteria are outlined for the more recently shelf-stable proposed PANS, the term most commonly (retaining 95% viability 2 years after date of manufacture) referred to now among specialists. While some work in the area has acid-resistant confused the picture and divided groups, (encased in hard spores that protect against stomach acid) others are working to clarify early research on PANDAS. A recent Italian study from 2013 provides a descriptive analysis of prebiotic-enhanced PANDAS and treatment outcomes.6 The (providing a reliable food source) summary of their findings is consistent what many of us see clinically: most PANDAS next-generation cases occur in boys, approximately 6 years old; the patients have elevated Strep probiotic supplement antibody titers; and more than 75% respond (reliably delivering results for your patients) positively to penicillin.5 Other important research by Kirvan et al has helped shed light on possible mechanisms, as well as unique antibodies which we can now test and quantify.7,8 Currently a multi-site, placebo-controlled trial is underway, For product literature, study manuscripts, free product conducted by Drs Swedo, Leckman, and Cunningham of the University of Oklahoma samples — or to order Prescript-Assist today — and testing the clinical application of intravenous immunoglobulin (IVIG) in call 888-919-8944 or visit www.prescript-assist.com children with PANDAS.

Testing Most probiotic supplements are plagued Prescript-Assist is different. The subject Although the term “autoimmune” has with problems. For starters, they’ve never of multiple human clinical studies, Prescript- been removed from the newer acronyms, been tested in human clinical trials. They Assist solves all these problems. Which is why autoimmunity is still a suspected mechanism. The names have been changed typically feature just a few strains of lactic it has been shown to consistently provide simply to de-emphasize the etiological acid based microflora, limiting their efficacy. positive patient outcomes.* agent. Dr Cunningham and her group at They’re easily destroyed by heat, pressure, the University of Oklahoma have been Available through healthcare professionals. working to explain possible mechanisms light, and stomach acid. And they lack in their 2006 paper, “Antibody-mediated prebiotics — the food probiotics need neuronal cell signaling in behavior and * This statement has not been evaluated by the Food and Drug Administration. to proliferate. This product is not intended to diagnose, treat, cure, or prevent any disease. movement disorders.”7 In this paper they describe several unique markers (eg, CaM kinase II and G1cNAc) in children with these syndromes, which are not n present in children with similar conditions Distributed by LL Magnetic Clay, Inc. Livermore, CA 94550 such as Tourette’s syndrome (TS) and NATUROPATHIC DOCTOR NEWS & REVIEWNEW ad ndnr-2.indd 1 april11/15/2012 2014 5:50:47 PM3 Client Phone AD Form ContaCt Fax Must be completed in full.

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childhood obsessive-compulsive disorder offered with their test. Additionally, they (OCD), that are not commonly thought are currently looking at other immune to be regulated by the immune system. markers that may explain why some kids A commercially available test developed test “unlikely” yet respond favorably to from this research is commonly referred treatments. For these reasons, this type to as the Cunningham panel, or “the of testing can be a difficult decision for PANDAS test” (sample report available at families and physicians alike. For example, ndnr.com). However, this testing method if a child were to test negative, that family does not come without drawbacks. Part of the challenge of working with may find it difficult to justify and pursue Firstly, insurance does not always cover neuroimmune conditions like PANS is that the immunological treatments. it, which can pose an obstacle for patients. As part of the diagnostic criteria for Secondly, the test rates a likelihood scale, as outcome of the treatment is often what verifies or PANDAS/PANS, other relevant disorders opposed to providing a definitive positive must be ruled out. Examples include or negative result. Lastly, several of our provides the diagnosis. metabolic disorders, seizures, Sydenham’s patients have tested “PANDAS unlikely,” chorea and other autoimmune disorders – yet have responded positively to immune part of a comprehensive list found in treatments. In a personal discussion with Dr Singer’s article, “Moving from PANDAS Dr Cunningham and her colleagues, to CANS.”3 Assuming these conditions they offered one possible explanation. have been ruled out and PANDAS or They propose that there are more unique PANS is a consideration, the tests in Table antibodies involved than what is currently 3 may be considered. These tests offer a starting place and are broken down into 2 tiers, based on our clinical evaluation of hundreds of suspected cases, though may need to be modified to each specific individual and his or her unique history.

Treatment Part of the challenge of working with neuroimmune conditions like PANS is that the outcome of the treatment is often what verifies or provides the diagnosis. Therefore, targeting the abnormal immune response, infectious agent, and supporting the susceptible host tends to be the foundation of our holistic approach. Once we have verified that a neuroimmune condition is what we are targeting, complementary or supportive therapies such as diet, herbs, supplements and IV infusions can be started.

Targeting Infectious Agents One first has to know what they are treating, however, which may not always be a bacterium or a virus (as was discovered in one of our recent patients who had elevated IgE levels of >1500, suspected parasite infection, and responded to positively to metronidazole). A short burst of steroids to quell the abnormal immune response and antibiotics to eradicate the infection are combined to create a common starting place if the suspected trigger is Strep or other bacterial trigger. Based on published studies and clinical experience, injectable penicillin, azithromycin, or amoxicillin and clavulanic acid (including XR versions) are reasonable starting medications.1,6 Oftentimes, a typical course of 5-10 days for common childhood Strep throat is not sufficient for a child with PANS, who may require 2-4 weeks of treatment. Although each case is unique, many kids would not have ALLY t IC es IN t L e C d had symptoms resolved had it not been

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e for either a longer course or higher dose r d m e A t to es of antibiotic than what is typical for that LogY t infectious agent. Antiviral medications and herbal formulas can be useful if the infectious agent or laboratory picture points to a possible viral contribution. As mentioned earlier, there are times where anti-parasitic agents can be useful as well.

Immune Modulation Additionally, immune-modulating treatments such as intravenous immunoglobulin (IVIG) may be considered later in the plan if there is evidence of an immune disorder that often has a favorable outcome with such a therapy, 4 april 2014 NATUROPATHIC DOCTOR NEWS & REVIEW AD FORM MUST BE COMPLETED IN FULL

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9 eg, a selective immune deficiency or an Table 1. Original PANDAS Diagnostic Criteria inadequate response to a vaccine such as All 5 of the following diagnostic criteria must be met for diagnosis: pneumococcal vaccine (in a vaccinated 1. Presence of obsessive-compulsive disorder (OCD) or a tic disorder child). I cannot stress enough how 2. Prepubertal symptom onset 3. Acute symptom onset and episodic (relapsing-remitting) course important dietary work is with all of our Volume 10 Issue 4 | April 2014 4. Temporal association between Group A streptococcal infection and symptom onset/exacerbations patients with tics, OCD, and/or anxiety; 5. Associated with neurological abnormalities (particularly motoric hyperactivity and choreiform movements) these conditions often respond well to Founders/Publishers Razi Ann Berry-Tallman (Courtesy, Susan E. Swedo) a decrease in immune stimulation. For David A. Tallman, DC, ND example, we have observed that a greater Table 2. Proposed Diagnostic Criteria for PANS9 [email protected] than usual number of kids with TS, tics, Criterion Description Medical Editor OCD, and/or PANS respond positively to I. Abrupt, dramatic onset of obsessive-compulsive disorder or severely restricted food intake Mary James, ND an elimination of peanuts from their diet, II. Concurrent presence of additional neuropsychiatric symptoms, with similarly severe and Associate Medical Editor with a gold standard reintroduction for acute onset, from at least 2 of the following 7 categories: David A. Tallman, DC, ND confirmation. Like with many autoimmune 1. Anxiety disorders, anti-inflammatories such as Contributing Editor, Education 2. Emotional lability and/or depression David Schleich, PhD steroids and NSAIDS are commonly 3. Irritability, aggression, and/or severely oppositional behaviors prescribed for PANS. Typically, a short Contributing Editors, Botanical Medicine 4. Behavioral (developmental) regression burst will produce improvements in Jillian Stansbury, ND Robin DiPasquale, ND, RH (AHG) symptoms within only a few days. 5. Deterioration in school performance We will often follow immune- 6. Sensory or motor abnormalities Contributing Editor, Homeopathy modulating treatments and anti- 7. Somatic signs and symptoms, including sleep disturbances, enuresis, or urinary frequency Joseph Kellerstein, DC, ND inflammatories with frequent doses of III. Symptoms are not better explained by a known neurologic or medical disorder, such as Contributing Editor, Oncology curcumin to prolong the anti-inflammatory Syndenham chorea, systemic lupus erythematosus, Tourette disorder, or others Jacob Schor, ND, FABNO effect. This seems to extend the time Note: The diagnostic work-up of patients suspected of PANS must be comprehensive Contributing Editor, Nature Cure between flare ups. To round out treatment enough to rule out these and other relevant disorders. The nature of the co-occurring Sussanna Czeranko, ND plans and support the “susceptible host” symptoms will dictate the necessary assessments, which may include MRI scan, lumbar we may also use IV infusion therapies such puncture, electroencephalogram, or other diagnostic tests. Contributing Editor, Functional Medicine Mark Swanson, ND as a Myers cocktail or single nutrients, (Courtesy, Susan E. Swedo) such as high doses of IV vitamin C or Table 3. Laboratory Testing: 2-Tier Evaluation of PANDAS or PANS Editorial Coordinator glutathione. IV glutathione can produce Tier 1 Scot Purvis [email protected] very quick positive responses in patients Lab Tests • Anti-streptolysin O (ASO) antibodies depleted of this important immune staple. • Anti-DNAse B antibodies Director of Sales and Marketing • Immunoglobulins IgA, IgE, IgG, IgM Matthew Knapp Gastrointestinal Support • IgG subclass 1-4 [email protected] • IgE food allergy profile To protect the integrity of the Circulation Manager • Local environmental allergy profiles (can be done in addition to scratch testing) gastrointestinal lining while using Tara Hall • IgG food sensitivities [email protected] NSAIDS, we will often suggest probiotics Note: Tier 1 is designed to reveal a picture of general immune reactivity. If these labs and clinical throughout the entire treatment period. picture suggest PANDAS/PANS, one may then proceed to Tier 2 testing if needed Creative Direction This is additionally helpful with Jaclyn Threadgill Tier 2 [email protected] concurrent antibiotics, as these can alter Lab Tests • Cunningham profile www.jthreadgill.com the microbiome, important for immune • Natural killer cell profile function and disease prevention. • Lyme disease antibodies • Pneumococcal vaccine titers (if vaccinated) Other Considerations • Mycoplasma antibodies • HHV-6 antibodies ND News & Review In differentiating between PANS and PO BOX 2968 • HSV antibodies (and other possible co-infections, if clinically relevant) common childhood conditions (eg, TS and Scottsdale, AZ 85252-2968 Note: Tier 2 testing can get quite comprehensive, and the possible co-infection list can be lengthy. 888.627.8677 OCD), we commonly view tics, OCD, and 480.275.7712 This is often why when PANDAS is suspected, immune-modulating or immune-suppressive treatments www.ndnr.com anxiety, in general, as immune-influenced are commonly employed. A positive response to immune-modulating treatments or antibiotics usually Our printer utilizes wind-power disease processes. This explains the indicates that what you are targeting is, in fact, a neuroimmune syndrome and not one of the other predictable positive response to dietary psychiatric conditions such as TS or OCD. changes. Other explanations that should Naturopathic Doctor News & Review be ruled out include inappropriate school ASO – Anti-streptolysin O, representing an exotoxin of Group A beta-hemolytic Streptococcus; Copyright © 2014 Naturopathic Doctor News & Review. All rights Anti-DNAseB – antibodies reflect exposure to Streptococcus; HHV-6 – Human herpesvirus-6; HSV – reserved. No portion of this publication may be copied, reproduced, placement, home stress, or environmental or redistributed without express written permission from the Herpes simplex virus; TS – Tourette’s syndrome; OCD – obsessive-compulsive disorder influences such as toxins or allergens; other publisher. Reprint information is available by contacting publisher@ ndnr.com. Naturopathic Doctor News & Review reserves the right possible explanations for tics can also often to edit or reject any submitted editorial or advertising. Opinions expressed by contributors and advertisers are not necessarily the be revealed using imaging such as MRI or often improve symptoms presenting like a problem for kids and providers, as some, opinions of Naturopathic Doctor News & Review or its principals.

CT scans. If a child presents on a stimulant PANS is guanfacine. Selective serotonin- though not all, kids with PANS have Naturopathic Doctor News & Review is published and circulated medication, we will often discontinue this, reuptake inhibitors (SSRIs) are often reportedly worsened on SSRIs. Behavioral as a complementary annual subscription (12 issues) to licensed naturopathic doctors (NDs) and students and graduates of CNME as stimulants can provoke and exacerbate prescribed when kids present with PANS- approaches such as “Habit Reversal recognized naturopathic colleges in North America, and certain suppliers to the profession. many of the symptoms described as PANS. like symptoms by psychiatrists unfamiliar Training” is rapidly gaining ground. Annual subscriptions (12 issues) are available to other healthcare A common ADHD medication that can with this condition. This can present quite Additionally, nutrients and supplements providers and NDs outside of North America: US $99; Canada & commonly used in these conditions are Mexico $129USD; Europe and Overseas $179USD. magnesium (300-800 mg/day); inositol (4 g Article Submissions BID-QID); 5-HTP (100-300 mg QD); NAC Articles should be original, previously unpublished, and should (1200-1800 mg/day). These suggestions cover a specific topic, protocol, modality, diagnostic, philosophy, commentary, or case study pertaining to naturopathic medicine can serve as a general starting place for rather than a general overview. Illustrations, photographs, charts kids with suspected PANS or tic disorders, and protocols are encouraged. Naturopathic Doctor News & Review does not reprint articles from other publications except alike, while waiting on laboratory results. under unusual circumstances. Typical word requirements are 700 to 2000 words per article. Topics of interest include: • Clinical pearls Conclusion • Case management/case studies What seems apparent to myself and our • Naturopathic philosophy • Practice building and business management team and other PANS specialists is that • Current trends and issues that affect naturopathic in a subgroup of children, their brains are physicians in your area • News, announcements, and event notices highly reactive and respond inappropriately • Development of new techniques or protocols to auto-antibodies, unique infections, • Abstracts and reviews • Discussions pertaining to diagnostics food, or other factors. These children then • Public/media relations and networking mount an immune response to foreign • Using technology to make practices more efficient and profitable invaders, which triggers behavioral and/ • Educational and grassroots programs that further the natu- or motor symptoms. Despite the fact that ropathic cause this disorder is often viewed or reported as • Any other trend, event, or development you believe is pertinent to the profession rare, it is seemingly much more common For more information regarding article submission, or to receive a than is diagnosed. Perhaps, again, this copy of submission guidelines, please contact [email protected]. Opinions expressed in NDNR do not necessarily reflect those of is because of broader definitions that this publication and its publishers. NATUROPATHIC DOCTOR NEWS & REVIEW april 2014 5 ad form Must be coMpleted in full

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now include other triggers beyond Strep. In our group’s testimony to the state Case study of Connecticut in 2013, advocating for insurance reimbursement and recognition I cannot stress enough how important dietary work Patient: 10-year-old male of this condition, we conservatively Chief Complaint: Tics and OCD estimated that approximately 162 000 US is with all of our patients with tics, OCD, and/or Relevant History: Recurrent sinus infections children, or 1-2% of all school aged children, from 1 to 4 years old; single bout of croup; suffer from this condition. Comparing that anxiety; these conditions often respond well to a antibiotics for various infections and trips to ER; number to the approximately 32 000 cases tonsillectomy/adenoidectomy at 2 years old of all childhood cancers and about 215 000 decrease in immune stimulation. Symptoms: Started with obsession and cases of type 1 and 2 diabetes combined in then moved to motor tics. His symptoms people 20 years and younger (representing worsened after a sore throat 2 years ago. less than 1% of that age group), one can Amoxicillin was given for sore throat, but it see what a significant problem we have first discovered. Dorris Rapp, MD, was continue to evaluate safe and effective didn’t help and he quickly developed crying at with identifying and properly treating our discussing this phenomenon in her 1992 treatment options and individualized school and obsessive thoughts. His pediatrician children suffering from PANS. book, Is This Your Child?10 Clearly, we treatment plans based on clinical case said it could not be PANDAS because throat The idea that mental disorders could must continue to ask more questions and reports and what we have learned from culture was negative. He was then referred to be triggered by an abnormal immune explore further research in the connection similar conditions. Much like anything in a psychiatrist, who said “possible PANDAS” but response is not new, yet its acceptance between the nervous system and the medicine, the futility of a one-size-fits-all diagnosed him with OCD and prescribed SSRIs. continues to be met with a surprising immune system. However, while we wait approach has never been more apparent At this point, he came to Wholeness Center. reluctance nearly 2 decades after it was for unified diagnostic criteria, we can than with this syndrome. Work-up: Ferritin; Total IgG/A/M/E; CRP; CBC; CMP; ASO titers; IgG subclasses 1-4; Mycoplasma IgG/IgM; S pneumonia IgG serotypes (14); Anti-DNase B antibodies; IgG food sensitivity panel Remarkable lab findings: ASO 190 (H); Anti-DNase B 289 (H); 30+ IgG reactive foods Treatment: Prednisone (30 mg PO QD x 5 days); IM penicillin G (2.5 million units in office); Probiotics; Curcumin (600 mg BID) Follow-up: 1 week later – Improved ability to write in school; fewer motor tics and intrusive thoughts; anxiety resolved and people outside of home commenting on changes and improvements 5 weeks later – Was sick recently and symptoms returned. Added a nutritional/herbal immune support formula (1 cap TID)

References 9-10 and sample lab report available online at ndnr.com

Steven Rondeau, ND, BCIA-EEG currently practices in Fort Collins, Colorado as part of a collaborative team at Wholeness Center. He graduated from SCNM and then continued his specialty training in developmental disorders and pediatrics in Utah before settling in north- ern Colorado. His focus is on the recovery of children with neurodevelopment disorders and psychiatric illness, using a combination of conventional and alternative therapies. He is a Defeat Autism Now (DAN!)- registered doctor and a Medical Academy of Pediatric Special Needs MAPS doctor, and currently serves on the medical advisory board for the PANDAS Resource Network. In addition, he is BCIA-EEG-certified in EEG bio- feedback, neurofeedback, and quantitative EEG analysis. He can be reached at [email protected]. References 1. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998;155(2):264-271. 2. Rondeau S. PANDAS: An Immune-Mediated Mental Illness. NDNR. 2010;6(12). https://ndnr.com/ autoimmuneallergy-medicine/pandas-an-immune- mediated-mental-illness/ 3. Singer HS, Gilbert DL, Wolf DS, et al. Moving from PANDAS to CANS. J Pediatr. 2012;160(5):725-731. 4. Macerollo A, Martino D. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept. Tremor Other Hyperkinet Mov (N Y). 2013 Sep 25;3. tre-03-167-4158-7. 5. Allen AJ, Leonard HL, Swedo SE. Case study: a new infection-triggered, autoimmune subtype of pediatric OCD and Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry. 1995;34(3):307-311. 6. Falcini F, Lepri G, Rigante D, et al. -FINAL-2252: Descriptive analysis of pediatric autoimmune neuropsychiatric disorder associated with streptococcus infection (PANDAS) in a cohort of 65 Italian patients. Pediatr Rheumatol. 2013;11(Suppl 2):P242. 7. Kirvan CA, Swedo SE, Snider LA, Cunningham MW. Antibody-mediated neuronal cell signaling in behavior and movement disorders. J Neuroimmunol. 2006;179(1-2):173-179. 8. Kirvan CA, Swedo SE, Heuser JS, Cunningham MW. Mimicry and autoantibody-mediated neuronal cell signaling in Sydenham chorea. Nat Med. 2003;9(7):914-920.

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