Buscar en
Neurología (English Edition)
Toda la web
Inicio Neurología (English Edition) The link between tics and streptococcal infection: A case report
Journal Information
Vol. 28. Issue 9.
Pages 592-593 (November - December 2013)
Vol. 28. Issue 9.
Pages 592-593 (November - December 2013)
Letter to the Editor
DOI: 10.1016/j.nrleng.2013.10.012
Full text access
The link between tics and streptococcal infection: A case report
Relación entre tics e infección estreptocócica: a propósito de un caso
E. Peña Llamas
Servicio de Neurología, Hospital Sanitas La Moraleja, Madrid, Spain
Article information
Full Text
Download PDF
Full Text
Dear Editor:

Tics are repetitive, stereotyped movements that may be suppressed voluntarily. Patients feel the need to perform them as a means of relieving a mental or physical sensation that precedes them1; the most frequent cause is Tourette syndrome (TS).2 Researchers have tried to establish a link between tics and infection with Group A β-haemolytic streptococcus (GABHS).3 With this in mind, we present the case of a tic arising years after the patient had experienced Sydenham chorea (SC), a condition associated with GABHS, and we discuss the relationship between those episodes.

The patient was a 9-year-old girl who had experienced acute predominantly right-sided chorea, preceded by changes in handwriting and scholastic achievement. Anti-streptolysin antibody (ASLO) titre 1152; echocardiography showing mild mitral regurgitation; normal brain MRI; normal ceruloplasmin; and normal metabolic and hormonal studies. After being diagnosed with SC, she was treated with haloperidol, which improved symptoms, but the chorea persisted during 2 years. Since that time, she has received monthly prophylactic treatment with penicillin G. At the age of 13, she reported motor disorder in the form of brusque dorsal flexion of the left ankle when walking, causing the joint to click. This event could be prevented voluntarily, although the patient felt inclined to provoke it in order to relieve a feeling of tension in that joint. Traumatology study yielded normal results. ASLO: 285 (similar to previous studies); pharyngeal exudate presented normal flora. Symptoms resolved spontaneously in 1 year without treatment.

The role played by GABHS in tic aetiopathogenesis is a topic of debate. Tics are known to be movement disorders that are frequently associated with streptococcal infection; on some occasions, they meet diagnostic criteria for TS.3 Nevertheless, the nature of this association is unclear.4 For example, we know that GABHS may provoke SC, which is the neurological autoimmune manifestation of rheumatic fever; it presents with chorea and other neuropsychiatric symptoms5 and tics in some cases.5,6 The same autoimmune mechanism may be involved in both syndromes. In fact, patients with SC have been described as being more susceptible to drug-induced tics than other patients.7 Doctors have also indicated that children with a prior history of tics are more likely to develop Sydenham chorea.8 In this sense, the autoimmune nature of this association between entities is reinforced by the concomitant finding of specific anti-basal ganglia antibodies and high ASLO titres in patients with TS.9 Lastly, another argument supporting the presence of an autoimmune aetiopathogenic link between tics and streptococcal infection is the description of paediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDA). This disorder is defined by relapsing-remitting episodes of tics and/or obsessive-compulsive disorder associated with a recent streptococcal infection and attributed to an autoimmune mechanism,10 although whether or not it really exists is currently a very controversial topic.11

In our case, the motor disorder described by the patient met clinical criteria for a tic, and was interpreted as a simple motor tic of the foot during walking. Such tics, while less frequent than others, have been described in the literature.12 Therefore, the presence of SC and tics in the same patient suggests yet again the possibility of a link between tics and streptococcal infection; the novel finding in our case is that the tic appeared years after SC. This being the case, our patient may have developed an increased propensity for tics after having SC. This would probably have been caused by the presence of circulating anti-basal ganglia antibodies. The possibility of there being a relapsing-remitting PANDA process due to reinfection was less likely, since ASLO titres were not high at the time when the tic appeared, the pharyngeal exudate culture was normal, and the patient was being treated prophylactically with penicillin.

In conclusion, although the association between tics and streptococcal infection is well-documented in the literature, the nature of that link is unclear, and further studies will be needed to offer an explanation.

T.D. Sanger, D. Chen, D.L. Fehlings, M. Hallett, A.E. Lang, J.W. Mink, et al.
Definition and classification of hyperkinetic movements in childhood.
Mov Disord, 25 (2010), pp. 1538-1549
B. Tijero-Merino, J.C. Gómez-Esteban, J.J. Zarranz.
Tics y síndrome de Gilles de la Tourette.
Rev Neurol, 48 (2009), pp. S17-S20
R.C. Dale, I. Heyman, R.A.H. Surtees, A.J. Church, G. Giovannoni, R. Goodman, et al.
Dyskinesias and associated psychiatric disorders following streptococcal infections.
Arch Dis Child, 89 (2004), pp. 604-610
A. Schrag, R. Gilbert, G. Giovannoni, M.M. Robertson, C. Metcalfe, Y. Ben-Shlomo.
Streptococcal infection, Tourette syndrome, and OCD is there a connection.
Neurology, 73 (2009), pp. 1256-1263
F. Cardoso.
Sydenham's chorea.
Handb Clin Neurol, 100 (2011), pp. 221-229
M.T. Mercadante, M.C. Campos, M.J. Marques-Dias, E.C. Miguel, J. Leckman.
Vocal tics in Sydenham's chorea.
J Am Acad Child Adolesc Psychiatry, 36 (1997), pp. 305-306
I.M. Freeman, A.M. Aron, J.E. Collard, M.C. Mackay.
The emotional correlates of Sydenham's chorea.
Pediatrics, 35 (1965), pp. 42
M.T. Mercadante, G.F. Busatto, P.J. Lombroso, L. Prado, M.C. Rosário-Campos, R. Do Valle, et al.
The psychiatric symptoms of rheumatic fever.
Am J Psychiatry, 157 (2000), pp. 2036-2038
D. Martino, G. Giovannoni.
Antibasal ganglia antibodies and their relevance to movement disorders.
Curr Opin Neurol, 17 (2004), pp. 425-432
S.F. Swedo, H.L. Leonard, M. Garvey, B. Mittleman, A.J. Allen, S. Perlmutter, et al.
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases.
Am J Psychiatry, 155 (1998), pp. 264-271
P. Gomes de Alvarenga, A.G. Hounie, E.C. Miguel.
The role of group A-hemolytic streptococcal infection in neuropsychiatric disorders. Pediatrics. 2008;122:1157.
Réplica de Kurlan R en nombre del Grupo de Estudio del Síndrome de Tourette en Pediatrics, 122 (2008), pp. 1157
Tic disorders. Sadock BJ, Sadock VA, editors. Kaplan and Sadock's synopsis of psychiatry. Filadelfia: Lippincott Williams & Wilkins; 2007. p. 1235–9.

Please cite this article as: Peña Llamas E. Relación entre tics e infección estreptocócica: a propósito de un caso. Neurología. 2013;28:592–593.

Copyright © 2012. Sociedad Española de Neurología
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.