Group A beta hemolytic streptococcal infections and obsessive-compulsive symptoms in a Turkish pediatric population


Osman Abali, MD, Istanbul Tıp Fakultesi, Cocuk Psikiyatrisi ABDk, 34390, Capa, Istanbul, Turkey. Email:


Abstract  The purpose of the present study was to evaluate obsessive-compulsive disease (OCD) in Turkish Children who had group A beta hemolytic streptococcal (GABHS) infections and those who had not. Thirty-one children and adolescents (the study group) were compared with 28 children and adolescents. The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores were rated between study group and control group. The mean score, obsession and compulsion scores of CY-BOCS in the study group were significantly higher than they were in the control group (P < 0.05). The GABHS infections should be assessed in the etiology of OCD in children. Considering GABHS infections may help the treatment of OCD.


The spectrum of childhood neuropsychiatric disorders, termed PANDAS has been described in recent years. PANDAS is characterized by a sudden onset of motor tics and obsessive-compulsive disease (OCD) following a group A beta hemolytic streptococcal (GABHS) infection. PANDAS closely follow the medical model of SC in which children manifest autoantibodies following a GABHS infection directed against the basal ganglia, resulting in abnormal movements and behavior.1–3 The PANDAS clinical course was characterized by a relapsing-remitting symptom pattern with significant psychiatric comorbidity accompanying the exacerbations; emotional lability, separation anxiety, nighttime fears and bedtime rituals, cognitive deficits, oppositional behaviors, and motoric hyperactivity were particularly common.4 Also children with PANDAS experience tics, obsessive-compulsive behavior, and perhaps other neuropsychiatric symptoms as an autoimmune response to streptococcal infection.5 GABHS infections cause a wide range of neuropsychiatric disorders, such as sydenham's chorea, tics, OCD and PANDAS.6

OCD is a very well known a psychiatric disorder. However PANDAS-related OCD has some differences when it is compared with non-PANDAS OCD. In particular, the onset and course of symptoms in children with PANDAS are different from the other group. PANDAS-related OCD is also easily distinguished from non-PANDAS OCD, because the latter patients have a slow, gradual symptom onset, while children in the PANDAS subgroup have an overnight ‘explosion’ of obsessive-compulsive symptoms, reaching maximal clinically significant impairment in 24–48 h.4,7 Exacerbations of neuropsychiatric symptoms begin within 7–14 days after the streptococcal infection and usually occur simultaneously (a throat culture obtained because of the recent onset of OCD and/or tics is positive).8,9

In this study we assessed the OCD symptoms in Turkish children who had positive throat cultures.



Thirty-one subjects were assessed as a study group due to positive throat cultures for GABHS infection (19 girls and 12 boys, aged 4–17 years; mean ± SD, 8 ± 2.9). Twenty-eight subjects were assessed as a control group due to negative throat cultures (11 girls and 17 boys, aged 4–13; mean ± SD, 8 ± 2.7).

Inclusion criteria for the study were (i) age ≤ 17 years; and (ii) referral for evaluation and treatment of upper respiratory system infection.

Exclusion criteria were (i) chronic medical disorder; (ii) existence of neurologic symptoms of disorders; (iii) taking any psychiatric drug treatment; and (iv) unwillingness to participate in the study.

After the first evaluation in the pediatric outpatient clinic, throat cultures were obtained from all patients in the microbiology department. All subjects were interviewed by the child and adolescent psychiatrist for assessment of their psychiatric condition at the third week. The reason for our assessment date (third week) is that exacerbations of neuropsychiatric symptoms begin within 7–14 days after the streptococcal infection.8,9 Interviewers had not had information about whether children's throat cultures were positive or negative. No concomitant psychotropic medications were permitted during the study. Also no psychotherapeutic intervention was applied to these cases during the study.

All of patients completed this assessment. Also patients and their parents provided written informed consent prior to enrolling in the study.


The OCD symptoms were rated by the CY-BOCS.10 The Turkish version of the CY-BOCS was used.11

Interviews of patients and all of obtained data were evaluated by two child and adolescent psychiatrists who had been educated and interrater correlation had been confirmed about using the CY-BOCS (n = 20, r = 0.963, P < 0.001).

Statistical analysis

SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA) was used for evaluation of obtained data. CY-BOCS scores of groups were compared. Statistical analysis was conducted using t-test.


The symptom severity of OCD (compulsion score, obsessive score and total score) were obtained using CY-BOCS. These scores were compulsion score (5.1 ± 4.3, mean ± SD), obsessive (4.6 ± 3.8) and total (9.7 ± 7.6) in the study group. The control group's scores were compulsion (0.9 ± 2.3), obsessive (2.2 ± 3.1) and total (3.1 ± 4.8). The mean score, obsession and compulsion score of CY-BOCS in the study group were significantly higher than in the control group (P < 0.05).

The most frequent obsessive symptom in the study group was something terrible happening (e.g. illness of self or loved one) (n = 13, 41.9%). The most frequent compulsive symptom was checking (e.g. doors, homework) (n = 16, 25.8%)(Table 1).

Table 1.  Obsessive and compulsive symptoms of study group
Compulsive symptomsNo. (%)Obsessive symptomsNo. (%)
Checking (e.g. doors, locks, homework, appliances)16 (25.8)Something terrible happening (e.g. fire, death, or illness of self or loved one)13 (41.9)
Ordering or arranging11 (35.5)Concerns with dirt, germs or environmental toxins10 (32.3)
Hand washing, showering, bathing, tooth brushing 8 (25.8)Concerns with illness or body's appearance 8 (25.8)
Repeating rituals (e.g. going in or out the door, up or down) 7 (22.6)Collecting, hiding, Concerns with losing of things 5 (16.1)
Measures to prevent harm to self or others 7 (22.6)Forbidden, aggressive or persevere sexual thoughts, images of impulses 3 (9.7)
Counting 3 (9.7)Lucky or unlucky numbers, magic thoughts 3 (9.7)
Ceremonial behavior 3 (9.7)Scrupulosity (religious obsessive) 2 (6.5)
Others10 (32.2)Others 8 (25.8)


OCD can be seen after the streptococcal infection.4 Results of presented study supported the above research in the Turkish population. In the pediatric outpatient clinic, pediatricians should be alert due to psychiatric results of GABHS infection.

In this study, symptoms of OCD had sudden onset. The first three weeks are particularly important for revealing OCD symptoms in these cases. OCD symptoms of all patients had begun suddenly after upper respiratory system infection. These findings have shown similarity with PANDAS criteria of National Institute of Mental Health.

This study showed that GABHS infections are not all caused OCD symptoms and non-GABHS are rarely caused OCD symptoms. Serological studies for GABHS subtypes and other host properties (e.g. genetic, immunologic, environment) should be assessed for PANDAS in future research. Also our data show that in spite of using antibiotic treatment (after the throat culture) it was not effective in preventing PANDAS symptoms within 3 weeks.

Patients and families should be informed about the future probable conditions for GABHS. This study may help in the understanding of GABHS infection and its neuropsychiatric results in Turkey.

Limitations of the study include having one rating for OCD symptoms (at the third week). Patients had been treated by antibiotic for upper respiratory infection. Also a more specific age group may be useful for the assessment of OCD symptom properties in PANDAS.