by Dr. Adam Klapperich, DO
PANDAS is an acronym for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. This post-strep disorder, however, is not as well-defined as Sydenham’s chorea, the neurological manifestation of rheumatic fever. PANDAS does have a body of evidence supporting its existence, though it remains a controversial diagnosis. PANS is an expanded clinical entity, standing for Pediatric Acute-onset Neuropsychiatric Syndrome and includes all cases of abrupt onset OCD, not just those associated with streptococcal infections. The role of autoimmunity in PANDAS remains controversial.
The hallmark of PANDAS, as opposed to classic OCD, is the abruptness of onset. With PANDAS, the obsessive thoughts, compulsive behaviors, motor and/or vocal tics (among other possible psychiatric symptoms) can develop overnight, reaching full scale intensity in 24-48 hours. OCD typically emerges over the course of weeks or months. Other symptoms of PANDAS can include acute onset mood swings, hyperactivity, separation anxiety, handwriting changes, and nocturnal enuresis. PANDAS typically has a relapsing/remitting course, leading some providers to prescribe antibiotic prophylaxis for suspected cases.
Diagnostically, the child must have acute onset of OCD/tics, typically in a pre-pubertal child, and an association with a Group A beta-hemolytic streptococcal infection. This is confirmed via throat culture. Also available to help establish past strep infection are Antistrepolysin O (ASO) titer, which rises 3-6 weeks after a strep infection, and Antistreptococcal DNAse B (AntiDNAse-B) titer, which rises 6-8 weeks after a strep infection. It should be noted that some children have chronically elevated titers.
Psychiatric treatment for this type of OCD and tic disorder are the same as for a typical diagnosis, with cognitive behavioral therapy the mainstay, and SSRI medications as needed. Obviously a confirmed active strep infection should be treated with antibiotic. In the case of a negative throat swab, if the child does meet criteria of acute onset OCD, it would be up to the discretion of the provider the risk versus benefit of a course of antibiotics for a possible occult infection.
There is limited evidence regarding prophylactic antibiotic treatment for PANDAS/PANS. A 2005 randomized controlled study did show 64% decrease in neuropsychiatric symptoms in 23 children with PANDAS treated prophylactically with Penicillin V-K or azithromycin. IV Immune globulin may be a consideration for severely ill patients. There is no formal treatment protocol for treating PANDAS/PANS.
Sources:
- NIMH website: Orefici, et al, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), Streptococcus pyogenes : Basic Biology to Clinical Manifestations, 2016.
- DSM-5