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Streptococcal infection, Tourette syndrome, and OCD

Is there a connection?

From the University College London (A.S.), Institute of Neurology, Royal Free Campus, London; Department of Social Medicine (R.G., C.M., Y.B.-S.), University of Bristol; Institute of Cell and Molecular Science (G.G.), Barts and The London School of Medicine and Dentistry, London; and UCLMS Department of Mental Health Sciences (M.M.R.), London, UK.

Address correspondence and reprint requests to Dr. Anette Schrag, Department of Clinical Neurosciences, Royal Free Campus, Institute of Neurology, University College London, London NW3 2PF, UK a.schrag{at}medsch.ucl.ac.uk.

Background: A causal relationship of common streptococcal infections and childhood neuropsychiatric disorders has been postulated.

Objective: To test the hypothesis of an increased rate of streptococcal infections preceding the onset of neuropsychiatric disorders.

Methods: Case-control study of a large primary care database comparing the rate of possible streptococcal infections in patients aged 2–25 years with obsessive-compulsive disorder (OCD), Tourette syndrome (TS), and tics with that in controls matched for age, gender, and practice (20 per case). We also examined the influence of sociodemographic factors.

Results: There was no overall increased risk of prior possible streptococcal infection in patients with a diagnosis of OCD, TS, or tics. Subgroup analysis showed that patients with OCD had a slightly higher risk than controls of having had possible streptococcal infections without prescription of antibiotics in the 2 years prior to the onset of OCD (odds ratio 2.59, 95% confidence interval 1.18, 5.69; p = 0.02). Cases with TS or tics were not more likely to come from more affluent or urban areas, but more cases lived in areas with a greater proportion of white population (p value for trend = 0.05).

Conclusions: The present study does not support a strong relationship between streptococcal infections and neuropsychiatric syndromes such as obsessive-compulsive disorder and Tourette syndrome. However, it is possible that a weak association (or a stronger association in a small susceptible subpopulation) was not detected due to nondifferential misclassification of exposure and limited statistical power. The data are consistent with previous reports of greater rates of diagnosis of Tourette syndrome or tics in white populations.

Abbreviations: CI = confidence interval; GP = general practice; OCD = obsessive-compulsive disorder; OR = odds ratio; PANDAS = pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; SI = streptococcal infection; TS = Tourette syndrome.

Supplemental data at www.neurology.org.

Editorial, page 1252.

e-Pub ahead of print on September 30, 2009, at www.neurology.org.

Supported by a grant from the Tourette Syndrome Association, USA.

Disclosure: Author disclosures are provided at the end of the article.

Received February 12, 2009. Accepted in final form July 31, 2009.

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