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VOCAL TICS IN SYDENHAM'S CHOREA
L E T T E R S TO T H E E D I T O R
warrants attention is the rapid onset. It was much quicker than his antidepressant response. This possibly suggests that serotonergic mechanisms other than the postsynaptic receptor down-regulation, associated with the antidepressant response, may be operating in the resolution of this patient‘s enuresis. This report supports previous evidence for the existence of a serotonergic mechanism in enuresis (Altemus et al., 1992; Mesaros, 1993), which may be at least partially independent of the serotonergic mechanism of mood disorders. David Sprenger, M.D. Eisenhower Army Medical Center Fort Gordon, GA Altemus M, Pigott T , Kalogeras KT et al. (1992), Abnormalities in the regulation of vasopressin and corticotropin releasing factor secretion in obsessive compulsive disorder. Arch Gen Psychiatry 49:9-20 American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-1v. Washington, DC: American Psychiatric Association Green W H (1995), Child and Adolescent Psychopharmacology, Baltimore: Williams & Wilkins, p 35 Klauber G T (1989), Clinical efficacy and safety of desmopressin in the treatment of nocturnal enuresis. / Pediatr 114(4 part 2):719-722 Mesaros JD (1993), Fluoxetine for primary enuresis. / A m Acad Child Adolesc Psychiatry 32:877-878
VOCAL TICS IN SYDENHAM’S CHOREA
To the Editor: Sydenham’s chorea (SC) is a neurological disorder, characterized by sudden involuntary jerking movements of the extremities and caused by an immunological cross-reaction with P-hemolytic streptococci affecting the basal ganglia. It is one of the major signs of rheumatic fever (RF). The description of psychiatric symptoms in SC was made since the initial work by Thomas Sydenham in 1686. More recently, many studies have showed the presence of obsessivecompulsive (OC) symptoms and obsessive-compulsive disorder (OCD) in SC (Swedo et al., 1993). OCD has also been described more frequently in patients with Tourettes syndrome (TS), and there are several lines of research suggesting that some forms of O C D may represent a variant expression ofTS (Leckman et al., 1992). Therefore, it would be interesting to look for tics in patients with SC. As far as we know, there are no systematic studies describing vocal tics in patients with SC. In fact, clinical differentiation between choreic movements and motor tics may be difficult, mainly for mild SC (Erenberg, 1992). Vocal tics, however, are easier to distinguish from other choreic movements and may clarify the presence of tics in SC patients.
J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 . M A R C H 1997
Future follow-up studies suggesting a higher frequency of TS in patients who have suffered from SC may reinforce the hypothesis of an immunological etiology for some TS patients, as well as for OCD patients (Sweedo and Kiessling, 1994). We are conducting a systematic study assessing the presence of OC symptoms, OCD, and tics in patients with RF with or without SC. RF was diagnosed according to the Jones criteria, antistreptolysin 0,and erythrocyte sedimentation rate measures. A psychiatric and neurological evaluation was done in all patients by a certified child psychiatrist and two child neurologists. The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version, Yale-Brown Obsessive Compulsive Scale, and Yale Global Tic Severity Scale have been administered to all patients. So far, we have already fully assessed 10 children who suffer from SC. The preliminary analysis of our SC sample showed not only the expected higher occurrence of OC symptoms (40%) but also the presence of vocal tics in eight patients (80%). These eight patients each had at least one kind of vocal tics: An 8-year-old boy had palilalia (with touching as OC symptom); a 13-year-old boy constantly repeated the words “no” and “nothing’ (with washing and skin picking as OC symptoms); a 9-year-old girl, an 8-year-old girl, and a 10year-old boy had a click (without O C symptoms); a 14year-old girl had a click, smack, and whistle (with washing, checking, and skin picking as OC symptoms); another 14year-old girl had throat clearing and click (without OC symptoms); and finally, a 9-year-old girl had sniffing (with checking as OC symptom). The rwo others were a 5-yearold boy who did not have any symptoms and an 11-yearold girl who had only trichotillomania. The finding of vocal tics in these patients may suggest that tics, as well as OCD, are more frequent in SC. Moreover, given that the basal ganglia has been implicated in the pathophysiology of SC, OCD, and TS (Baxter et al., 1990), their different presentation may reflect the difference of dysfunction within the cortex-thalamus-striatum-cortex circuits. Future research should focus on the underlying etiological and pathophysiological mechanisms that mediate these dysfunctions. Marcos Tomanik Mercadante, M.D. Maria Conceicao do Rosario Campos, M.D. Maria Joaquina Marques-Dias, M.D., Ph.D. Euripedes Constantino Miguel, M.D., Ph.D. Sao Paulo University Medical School, Brazil James Leckman, M.D. Yale University, New Haven, CT
305
LETTERS TO T H E E D I T O R
Barer LR, Schwartz JM, Guze BH et al. (1990),Neuroimaging in obsessivecompulsive disorder: seeking the mediating neuroanatorny. In: Obsersive Compulrive Disorder: Theoy and Management, 2nd ed, Jenike MA, Baer L, Minichiello WE, eds., Chicago: Year Book Medical Publishers, pp 167-188 Erenberg G (1992), Tourerre’s Syndrome and other tic disorders. In: Child and Adolescent Neurology for Psychiatrists, Kaufman DM, Solomon GE, Pfeffer CR, eds. Baltimore: Williams & Wilkins, pp 67-78 Leckman JF, Pads DL, Peterson BS, er al. (1992), Pathogenesis ofTourerre syndrome: clues from the clinical phenotype and natural history. Adv Neurol, 58: 15-24 Swedo S, Kiessling L (1994), Specularions on antineuronal anribodymediated neuropsychiatric disorders of childhood. Pediatrics 93:323-326
The Letrers column is a corner of the Journal which encourages opinion, controversy, and preliminary ideas. We especially invite reader comments o n rhe articles we publish as well as issues or interests of concern to child and adolescent psychiatry. The Editor reserves the right to solicir responses and publish replies. All starements expressed in this column are those of the authors and do not reflect opinions of the Journal. Letters should not exceed 750 words, including a maximum of 5 references. They must be signed, typed doublespaced, and submitted in duplicate. All letters are subject to ediring and shortening. They will be considered for publication but may nor necessarily be published nor will their receipt be acknowledged. Please direct your letters to John F. McDermotr, Jr., M.D., Editor, Journal ofthe AAC4P, University of Hawaii School of Medicine, Kapiolani Medical Center, 1319 Punahou Streer #635, Honolulu, H I 968261032.
Coming in April: Foster Care: An Update Alvin A Rosenfeld et al.
+
Incidence of Depression in Adolescents Carol Z. Garrison et al.
+
Nefazodone for Mood Disorders Timothy E. Wilens et al.
+
Gender Differences in Substance Abuse Catherine A. Martin et a!.
+
MPD in ADHD: Does Body Mass Predict Clinical Response? Mark D. Rappoport and Colin Denney
+
Clonidine Use in Children Dennis I? Cantwell et al.
306
J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:3, MARCH 1997
warrants attention is the rapid onset. It was much quicker than his antidepressant response. This possibly suggests that serotonergic mechanisms other than the postsynaptic receptor down-regulation, associated with the antidepressant response, may be operating in the resolution of this patient‘s enuresis. This report supports previous evidence for the existence of a serotonergic mechanism in enuresis (Altemus et al., 1992; Mesaros, 1993), which may be at least partially independent of the serotonergic mechanism of mood disorders. David Sprenger, M.D. Eisenhower Army Medical Center Fort Gordon, GA Altemus M, Pigott T , Kalogeras KT et al. (1992), Abnormalities in the regulation of vasopressin and corticotropin releasing factor secretion in obsessive compulsive disorder. Arch Gen Psychiatry 49:9-20 American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-1v. Washington, DC: American Psychiatric Association Green W H (1995), Child and Adolescent Psychopharmacology, Baltimore: Williams & Wilkins, p 35 Klauber G T (1989), Clinical efficacy and safety of desmopressin in the treatment of nocturnal enuresis. / Pediatr 114(4 part 2):719-722 Mesaros JD (1993), Fluoxetine for primary enuresis. / A m Acad Child Adolesc Psychiatry 32:877-878
VOCAL TICS IN SYDENHAM’S CHOREA
To the Editor: Sydenham’s chorea (SC) is a neurological disorder, characterized by sudden involuntary jerking movements of the extremities and caused by an immunological cross-reaction with P-hemolytic streptococci affecting the basal ganglia. It is one of the major signs of rheumatic fever (RF). The description of psychiatric symptoms in SC was made since the initial work by Thomas Sydenham in 1686. More recently, many studies have showed the presence of obsessivecompulsive (OC) symptoms and obsessive-compulsive disorder (OCD) in SC (Swedo et al., 1993). OCD has also been described more frequently in patients with Tourettes syndrome (TS), and there are several lines of research suggesting that some forms of O C D may represent a variant expression ofTS (Leckman et al., 1992). Therefore, it would be interesting to look for tics in patients with SC. As far as we know, there are no systematic studies describing vocal tics in patients with SC. In fact, clinical differentiation between choreic movements and motor tics may be difficult, mainly for mild SC (Erenberg, 1992). Vocal tics, however, are easier to distinguish from other choreic movements and may clarify the presence of tics in SC patients.
J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 . M A R C H 1997
Future follow-up studies suggesting a higher frequency of TS in patients who have suffered from SC may reinforce the hypothesis of an immunological etiology for some TS patients, as well as for OCD patients (Sweedo and Kiessling, 1994). We are conducting a systematic study assessing the presence of OC symptoms, OCD, and tics in patients with RF with or without SC. RF was diagnosed according to the Jones criteria, antistreptolysin 0,and erythrocyte sedimentation rate measures. A psychiatric and neurological evaluation was done in all patients by a certified child psychiatrist and two child neurologists. The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version, Yale-Brown Obsessive Compulsive Scale, and Yale Global Tic Severity Scale have been administered to all patients. So far, we have already fully assessed 10 children who suffer from SC. The preliminary analysis of our SC sample showed not only the expected higher occurrence of OC symptoms (40%) but also the presence of vocal tics in eight patients (80%). These eight patients each had at least one kind of vocal tics: An 8-year-old boy had palilalia (with touching as OC symptom); a 13-year-old boy constantly repeated the words “no” and “nothing’ (with washing and skin picking as OC symptoms); a 9-year-old girl, an 8-year-old girl, and a 10year-old boy had a click (without O C symptoms); a 14year-old girl had a click, smack, and whistle (with washing, checking, and skin picking as OC symptoms); another 14year-old girl had throat clearing and click (without OC symptoms); and finally, a 9-year-old girl had sniffing (with checking as OC symptom). The rwo others were a 5-yearold boy who did not have any symptoms and an 11-yearold girl who had only trichotillomania. The finding of vocal tics in these patients may suggest that tics, as well as OCD, are more frequent in SC. Moreover, given that the basal ganglia has been implicated in the pathophysiology of SC, OCD, and TS (Baxter et al., 1990), their different presentation may reflect the difference of dysfunction within the cortex-thalamus-striatum-cortex circuits. Future research should focus on the underlying etiological and pathophysiological mechanisms that mediate these dysfunctions. Marcos Tomanik Mercadante, M.D. Maria Conceicao do Rosario Campos, M.D. Maria Joaquina Marques-Dias, M.D., Ph.D. Euripedes Constantino Miguel, M.D., Ph.D. Sao Paulo University Medical School, Brazil James Leckman, M.D. Yale University, New Haven, CT
305
LETTERS TO T H E E D I T O R
Barer LR, Schwartz JM, Guze BH et al. (1990),Neuroimaging in obsessivecompulsive disorder: seeking the mediating neuroanatorny. In: Obsersive Compulrive Disorder: Theoy and Management, 2nd ed, Jenike MA, Baer L, Minichiello WE, eds., Chicago: Year Book Medical Publishers, pp 167-188 Erenberg G (1992), Tourerre’s Syndrome and other tic disorders. In: Child and Adolescent Neurology for Psychiatrists, Kaufman DM, Solomon GE, Pfeffer CR, eds. Baltimore: Williams & Wilkins, pp 67-78 Leckman JF, Pads DL, Peterson BS, er al. (1992), Pathogenesis ofTourerre syndrome: clues from the clinical phenotype and natural history. Adv Neurol, 58: 15-24 Swedo S, Kiessling L (1994), Specularions on antineuronal anribodymediated neuropsychiatric disorders of childhood. Pediatrics 93:323-326
The Letrers column is a corner of the Journal which encourages opinion, controversy, and preliminary ideas. We especially invite reader comments o n rhe articles we publish as well as issues or interests of concern to child and adolescent psychiatry. The Editor reserves the right to solicir responses and publish replies. All starements expressed in this column are those of the authors and do not reflect opinions of the Journal. Letters should not exceed 750 words, including a maximum of 5 references. They must be signed, typed doublespaced, and submitted in duplicate. All letters are subject to ediring and shortening. They will be considered for publication but may nor necessarily be published nor will their receipt be acknowledged. Please direct your letters to John F. McDermotr, Jr., M.D., Editor, Journal ofthe AAC4P, University of Hawaii School of Medicine, Kapiolani Medical Center, 1319 Punahou Streer #635, Honolulu, H I 968261032.
Coming in April: Foster Care: An Update Alvin A Rosenfeld et al.
+
Incidence of Depression in Adolescents Carol Z. Garrison et al.
+
Nefazodone for Mood Disorders Timothy E. Wilens et al.
+
Gender Differences in Substance Abuse Catherine A. Martin et a!.
+
MPD in ADHD: Does Body Mass Predict Clinical Response? Mark D. Rappoport and Colin Denney
+
Clonidine Use in Children Dennis I? Cantwell et al.
306
J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:3, MARCH 1997