Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

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I wish all success to your journal and look forward to sending you any suitable similar article in future"



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Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Case report
Year : 2011 | Month : November | Volume : 5 | Issue : 6 | Page : 1298 - 1300

Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): A Case Report

Mona Srivastava, Ganesh Shankar, M.N.Tripathi

M.D., Assistant Professor, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. 221005 MBBS, Second year Junior Resident, Department of Psychiatry, Institute of Medical Sciences Banaras Hindu University, Varanasi, India. 221005 M.D, Senior Resident, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India .221005

Correspondence Address :
Mona Srivastava
36/2HIG Kabir Nagar Colony,
Durgakund, Varanasi. (UP) 221005, India
Phone : 09336910619
E mail : drmonasrivastava@gmail.com

Abstract

Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is a unique syndrome which is associated with a recent infection which is caused by the group A streptococcal haemolytic bacteria. A seeming dearth of cases being report from India, despite the high incidence of the infection in the country, is being highlighted in this case report.

Keywords

Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), group A beta-haemolytic streptococci (GABHS), Anti streptolysin O titer (ASO).

Introduction
Several studies have shown the role of immunological factors in the causation of Obsessive compulsive disorder (OCD)(1). The most important support to the immunological hypothesis for OCD comes from the studies on Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS)(2). Streptococcal infections, specifically the ones which are caused by the b-haemolytic Group A Streptococci, are a unique constellation of disorders which have been clubbed under a syndrome which has been named as PANDAS, and the various diagnostic criteriae are as per NIMH (National Institute of Mental Health) (2), which are shown in (Table/Fig 1),(Table/Fig 2). Although b-haemolytic streptococcal infection is prevalent in India (3), not a single case has been reported from here (1), which classically fulfills the NIMH guidelines (2). Since the constellation of the symptoms can be severely debilitating at times, it is important to be aware of the disorder in order to prevent it (4). The few reports and the poor understanding of this condition need to be overcome. We report a case here, which fulfills all the criteriae of this unique disorder, with an aim to substantiate the existing database.

Case Report

The patient S, a 10 year-old muslim male, studying in the 4th standard, hailing from an urban area, presented to the outpatient psychiatric clinic of the university hospital with a sudden onset of motor and vocal tics along with obsessions regarding contamination and washing compulsions. At around 6 years of age, S had developed fever, cough, pain in the abdomen and breathlessness and the diagnosis of pneumonitis was made by the treating paediatrician. After the treatment, his general condition had improved, but it was noticed that the otherwise quite child had become very restless. Within two weeks following his discharge from the paediatric unit, S started having some complex movements .There was repeatedforceful closure of the eyes, followed by blinking, facial grimacing, head jerking, shoulder shrugging, coughing, hand rubbing and nose-rubbing which ended with a loud throat clearing and a clucking sound. The entire sequence of the movements which have been described above were monotonously repeated several times during the day ;however the movements ceased during sleep. His condition worsened with time, he started washing his hands excessively, took a lot of time and water for taking bath, his sleep and appetite decreased markedly and he became irregular in school. Over time, the sounds from his neck became very loud and started causing embarrassment to the patient. The patient has been taken for multiple consultations, without any improvement. The patient is unable to control his movements and on trying to do so, his tics returned with greater complexity, intensity, and frequency. He dropped school because of his illness. After about six months, there was a sudden decrease in all his symptoms and this prompted him to join school. Three months later, following a bout of cough and sore throat, the symptoms returned, with greater intensity. Several days later, the patient had an equally abrupt onset of obsessions and compulsions, involving ordering and arranging, contamination, and counting. He used to count the number of steps that he moved forward and then backwards and this made it tiring for him to move a couple of steps. A family member observed that the patient stood in one place for a long time and that he had to be pushed at times to move forward. For the past four years, his symptoms had been persisting, although there had been remissions in the severity of the symptoms. His family members sought various consultants and even took the help of several faith healers and visited sacred places for the recovery of the patient. The patient was referred for a psychiatric consultation about six months back and since then, he is under the care of the psychiatric team. Before beginning the treatment, the patient was investigated by a CT scan and an anti sreptolysinO (ASO) titer. The CT scan revealed areas of demylenation in the basal ganglia region and the ASO titers were found to be markedly raised to 300 units. A diagnosis of PANDAS was made and the management was started. He is receiving tab haloperidol in the dose of 5mg/day and tab fluoxetine in the dose of 40mg/day on an outpatient basis. He turned up for follow up at 3 week intervals and reported an improvement in his symptoms including the vocal tics, the motor tics and the obsessive features. These improvements were reflected in his enhanced social functioning, a better quality of life and good compliance to medication at six months of follow up. On follow up, he complained of fever with sore throat and an exacerbation in his symptoms. At that time, he was also given a course of azitrhromycin for one week, which gave him subsequent relief from the condition. The psychiatric medication was continued; the improvement in the condition was maintained.

Discussion

The case which is being described by us, is probably the first case of PANDAS, as the literature search reveals that only few cases have been reported (4),(5) and that none of the cases could classically fitinto the stipulated diagnostic criteria (2). In their review, Reddy et al., (1) reported that no case of PANDAS was documented from India . Andrade and Pfizer (5) reported a case that did not have a pre pubescent onset of symptoms and the tics were not well defined. The case which was described by Shankarnarayan and John (4) also had an adult onset of symptoms and clumsiness instead of the clear tics .On the contrary, our case fits the classical description which is laid down by the NIMH (2). It has been suggested that in OCD, following an infection, the antibodies to the bacteria may make their way into the healthy brain and attack the basal ganglia, which could disrupt the normal brain (6). A subgroup of children with OCD seemed to have their symptoms triggered or exacerbated by the group A beta haemolytic streptococcal infection (GABHS). The symptoms seemed to have been caused from the caudate swelling that occurred in these subjects because of an autoimmune reaction between the caudate tissue and the anti neuronal antibodies which were formed against GABHS (6). This subtype of OCD which is called Paediatric Auto-immune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS), is characterized by a sudden and dramatic onset or exacerbation of OCD or the tic symptoms and is associated with neurological findings, and a recent streptococcal infection (2).There is no evidence of any specific time limit from the occurrence of the infection to the onset of the symptoms; at the most, a ‘temporal’ correlation has to be established(2).The case which has been presented by us probably had a similar progress of events, as was evidenced by the demylenation which was found in the basal ganglia region in the CT scan, the association of the onset of the symptoms being preceded by a chest and throat infection. The infection which was caused by the group A streptococci, being the commonest infection in India, it may be the probable causative organism (3). This was also validated by an increased ASO titer which was found on investigation. As was described in the diagnostic criteriae, our case also had an abrupt onset and exacerbations which were associated with a relapse of the streptococcal infection. The PANDAS clinical course was characterized by a relapsing-remitting symptom pattern, with a significant psychiatric co morbidity accompanying the exacerbations. Emotional lability, separation anxiety, night time fears and bed time rituals, cognitive deficits, oppositional behaviours, and motoric hyperactivity are the particularly common symptoms which have been observed (7). Our case also had significant co morbidity in the form of obsessions ,compulsions, rituals and complex motor and vocal tics, along with significant features of anxiety and disturbances in sleep . The symptom onset in PANDAS is usually triggered by the GABHS infection; however, it has been well accepted that not all exacerbations are preceded by the group A beta-haemolytic streptococci (GABHS) infections, and that a prospective follow up is required to establish this association (2).Our case had exacerbations during the course of the illness, but they were not always associated with the GABHS infection. It should however be mentioned here, that the symptoms cannot be a mere coincidence, as the CT scan changes along with the raised ASO titers and the drug responses, are corroborative of the occurrence of the syndrome. The aetiology of PANDAS is unknown; the possible causes include an autoimmune antibody or a streptococcal toxin (7). PANDAS is by no means a confirmed diagnostic entity. However, Murphy et al. (8) recently helped in validating it as a disorder which was characterized by high streptococcal antibody titers. Episodic or saw tooth course symptom exacerbations were associated with elevations in the antibody titers. Our case had all the above features, though the temporal association of the symptom exacerbation with the raisedantibody titers was demonstrated only once.

We reported this case since it is important to keep this disorder in mind when treating children. The presence of the significant co morbidity can lead to a marked disability in terms of the academic performance and the social adjustments in these children and hence a timely intervention can be helpful (8) .Our case also lost important school years because of this illness. The lack of cases of PANDAS in the Indian context can be attributed to an inadequate awareness regarding this disorder and an infrequent liaison among the various specialties. A good cross referral between the paediatricians and the psychiatrists can serve in decreasing and eliminating the morbidity and the disability which are associated with this disease. It should also be emphasized here, that a seemingly innocuous infection of GABHS needs an optimal longitudinal management plan and follow-up.

Key Message

Awareness regarding the sequel of the streptococcal infection has to be increased and a timely and adequate treatment of the infection needs to be emphasized.

References

1.
Reddy YCJ,Rao NP, Khanna S.An overview of Indian research in obsessive compulsive disorder. Indian J Psychiatry 2010;52:S200-9.
2.
Swedo SE, Leonard HL, Garvey M, Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: Clinical description of the first 50 cases. Am J Psychiatry 1998;155:264- 71.
3.
Nandi S, Kumar R, Ray P, Vohra H, Ganguly NK. Group A streptococcal sore throat in a periurban population of northern India: A one-year prospective study. Bull World Health Organ 2001;79:528–33.
4.
Shankarnarayan A,John JK. Paediatric Autoimmune Neuropsychiatric Disorder Syndrome(PANDAS):A case report.Natl Med J India 2003 ;16(1) :22-3.
5.
Andrade C, Pfizer N. Sore throat and obsessions: A causal link?. Indian J Psychiatry 2006;48:130-1
6.
Husby G, van de Rijn I, Zabriskie JB, Abdin ZH, Williams RC Jr. Antibodies reacting with the cytoplasm of the subthalamic and the caudate nuclei neurons in chorea and acute rheumatic fever. J Exp Med 1976;144:1094–110.
7.
Bodner SM, Morshed SA, Peterson BS. The question of PANDAS in adults. Biol Psychiatry 2001;49:807-10.
8.
Murphy ML, Pichichero ME. Prospective identification and treatment of children with paediatric autoimmune neuro¬psychiatric disorder associated with Group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med 2002;156: 356-61

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