Friday, July 10, 2009


Here's a picture you put up in your pediatrics office for the kids. Isn't the 7-month old panda cub cute? Note: This is a tough case, initially planned to be two parts, but it's Friday!

An 8 year old girl presents to your pediatrics clinic complaining of abrupt onset fever, sore throat, headache, abdominal pain, nausea, and vomiting. You look into her oropharynx and see this:

On exam, you also note tender and enlarged anterior cervical lymph nodes and palatal petechiae. You swab the tonsils and posterior pharynx and send it off for culture. The blood agar plate is shown below. Disc A contains bacitracin.

Oh, but there's more! The patient's mother brings her in a week later because of acute onset of tic-like movements. She also has obsessive-compulsive behaviors like counting and cleaning. On examination, you notice choreiform movements. You prescribe antibiotics and the symptoms improve.

Challenge: What is this strange movement disorder?

Related Questions:
1. What did the patient initially present with?
2. Describe the colonies on the blood agar.
3. What laboratory tests would you send to confirm the diagnosis?

First image is in the public domain; second and third images are shown under fair use.


Stephanie said...

PANDAS!!! but i think the existence of this syndrome is still debated. GAS, strep throat, test for the antigen or ab in the blood (don't remember which sorry).

i really like the panda.

you will really like the pinata this weekend. it's a burro. his name is larry.

Alex said...

syndenham's chorea?

Craig Chen said...

ooooh interesting. Steph's right, I was going for PANDAS but I think Syndenham's chorea is a reasonable diagnosis.


The girl initially presented with signs and symptoms of acute pharyngitis. The culture shows large zones of clear beta-hemolysis with a zone of inhibition around bacitracin. This suggests group A beta-hemolytic Strep pyogenes. Laboratory tests include anti-streptolysin (ASO) and anti-DNase B titers. One rare nonsuppurative complication of strep pharyngitis is PANDAS syndrome or pediatric autoimmune neuropsychiatric disorder associated with group A streptococcus. This is a controversial syndrome with acute onset, episodic OCD or tic disorder in children associated with GAS infections.

Sources: UpToDate;; Wikipedia.