Is a trial of steroids, such as prednisone (prednisone), worth considering for a 4-year-old with persistent tics due to asymptomatic streptococcal (strep) infection?

Steroids Are Not Recommended for Tics Following Asymptomatic Strep Infection in Children

Corticosteroid therapy is not recommended for treating persistent tics in a 4-year-old child with a history of asymptomatic streptococcal infection. 1 The potential adverse effects of systemic steroids outweigh the unproven benefits in this clinical scenario.

Rationale for Not Using Steroids

Evidence Against Steroid Use

• The Infectious Diseases Society of America (IDSA) specifically recommends against adjunctive corticosteroid therapy for streptococcal infections (weak recommendation, moderate evidence) 1
• Corticosteroids carry significant risks, especially in children, including:
  • Behavioral changes
  • Increased appetite and weight gain
  • Hypothalamic-pituitary-adrenal axis suppression
  • Immunosuppression increasing risk of infections
  • Potential for growth suppression with prolonged use 2

PANDAS/PANS Considerations

While this case suggests possible PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections), it's important to note:

• PANDAS remains a controversial diagnosis with insufficient evidence to support immune-modulating therapies 3
• The persistence of tics for 5 months suggests a chronic condition rather than the typical relapsing-remitting pattern seen in classic PANDAS 4
• There is insufficient evidence to support routine use of corticosteroids for PANDAS/PANS-related tics 3

Recommended Management Approach

1. Confirm the diagnosis:

   • Verify the association between streptococcal infection and tics through detailed history
   • Consider other causes of tics in children this age

2. First-line treatment options:

   • Behavioral therapy approaches for tic management
   • Consider symptomatic treatment with standard tic medications if tics are severe or causing functional impairment

3. Antimicrobial considerations:

   • Ensure complete eradication of streptococcal infection if still present
   • Consider prophylactic antibiotics only if there is a clear pattern of strep-triggered exacerbations

4. Monitoring:

   • Regular follow-up to assess tic severity and impact on functioning
   • Watch for any new neuropsychiatric symptoms that might suggest PANDAS exacerbation

Important Caveats

• The diagnosis of PANDAS requires meeting specific criteria, including abrupt symptom onset and a relapsing-remitting course 4
• Many children with tics have a natural waxing and waning course unrelated to infection
• The long duration (5 months) suggests this may not be a typical PANDAS presentation, which often shows more dramatic fluctuations with infections

Given the lack of evidence supporting steroid use for this condition and the significant potential for adverse effects, especially in young children, corticosteroid therapy should be avoided in favor of more established and safer treatment approaches.