Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood

Background In children, exacerbations of ties and obsessive symptoms may oc cur after infection with group A P-haemolytic streptococci. If post-strepto coccal autoimmunity is the cause of the exacerbations, then children might respond to immunomodulatory treatments such as plasma exchange or intraveno us immunoglobulin (IVIG), We studied whether plasma exchange or IVIG would be better than placebo (sham IVIG) in reducing severity of neuropsychiatric symptoms. Methods Children with severe, infection-triggered exacerbations of obsessiv e-compulsive disorder (OCD) or tic disorders, including Tourette syndrome, were randomly assigned treatment with plasma exchange (five single-volume e xchanges over 2 weeks), IVIG (1 g/kg daily on 2 consecutive days), or place bo (saline solution given in the same manner as IVIG), Symptom severity was rated at baseline, and at 1 month and 12 months after treatment by use of standard assessment scales for OCD, ties, anxiety, depression, and global f unction. Findings 30 children entered the study and 29 completed the trial. Ten rece ived plasma exchange, nine IVIG, and ten placebo. At 1 month, the IVIG and plasma-exchange groups showed striking improvements in obsessive-compulsive symptoms (mean improvement on children's Yale-Brown obsessive compulsive s cale score of 12 [45%] and 13 [58%], respectively), anxiety (2.1 [31%] and 3.0 [47%] improvement on National Institute of Mental Health anxiety scale) , and overall functioning(2.9 [33%] and 2.8 [35%] improvement on National I nstitute of Mental Health global scale). Tic symptoms were also significant ly improved by plasma exchange (mean change on Tourette syndrome unified ra ting scale of 49%). Treatment gains were maintained at 1 year, with 14 (82% ) of 17 children "much' or "very much" improved over baseline (seven of eig ht for plasma exchange, seven of nine for IVIG), Interpretation Plasma exchange and IVIG were both effective in lessening of symptom severity for children with infection-triggered OCD and tic disorde rs. Further studies are needed to determine the active mechanism of these i nterventions, and to determine which children with OCD and tic disorders wi ll benefit from immunomodulatory therapies.