What is PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections)?

From the Guidelines

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) is a condition where strep throat triggers sudden-onset neuropsychiatric symptoms in children, characterized by the abrupt appearance or worsening of obsessive-compulsive disorder (OCD) symptoms and/or tic disorders. The condition is believed to result from an autoimmune response where antibodies produced to fight the strep bacteria mistakenly attack brain cells, particularly in the basal ganglia region that controls movement and behavior 1. Some key characteristics of PANDAS include:

• Abrupt appearance or worsening of OCD symptoms and/or tic disorders following a streptococcal infection
• Anxiety, emotional lability, separation anxiety, behavioral regression, deterioration in handwriting, sleep disturbances, and urinary frequency
• Typically affects children between 3 and 12 years old
• Believed to result from an autoimmune response where antibodies produced to fight the strep bacteria mistakenly attack brain cells Treatment typically involves antibiotics like penicillin or amoxicillin to eliminate the strep infection, cognitive behavioral therapy for OCD symptoms, and sometimes anti-inflammatory medications or immunomodulatory treatments in severe cases 1. It's essential for parents to seek medical attention if their child develops sudden behavioral changes following a strep infection, as early diagnosis and treatment can help prevent symptom progression and reduce the risk of recurrence. Recent research has shifted from PANDAS to a broader disorder — pediatric acute-onset neuropsychiatric syndrome — which is characterized by the sudden onset of obsessive–compulsive symptoms that can occur in response to a range of infections and other insults 1. However, the current state of knowledge dictates that the concept of PANDAS should be considered only as a yet-unproven hypothesis, and routine laboratory testing for GAS to diagnose, long-term antistreptococcal prophylaxis to prevent, or immunoregulatory therapy to treat exacerbations of this disorder is not recommended 1.

From the Research

Definition of PANDAS

• PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) is a subtype of acute-onset obsessive-compulsive disorder (OCD) thought to be caused by an autoimmune response to group A streptococcal infection 2.
• It is characterized by a sudden onset of obsessive-compulsive disorder (OCD) and/or tics after a group A Streptococcus (GAS) infection 3.

Clinical Characteristics

• The syndrome typically presents with a sudden onset of symptoms, including OCD, tics, and other neuropsychiatric symptoms 4.
• Tics are present in all patients, with the eyes and neck/head being most often involved 3.
• Vocal tics, behavioral changes, and OCD are also common symptoms 3.

Treatment

• Antibiotics, such as penicillin and azithromycin, have been shown to be effective in decreasing streptococcal infections and neuropsychiatric symptom exacerbations among children in the PANDAS subgroup 5.
• Immunomodulatory interventions, such as intravenous immunoglobulin and plasma exchange, have also been used to treat PANDAS, but the literature on their effectiveness is limited 2.
• Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) are still the first line of recommendation for acute onset OCD spectrum 4.

Controversies and Limitations

• The diagnosis and treatment of PANDAS are still controversial, and clinical consensus regarding optimal treatment strategy is lacking 2.
• Surgical treatment, such as tonsillectomy or adenotonsillectomy, has not been shown to impact the clinical course of the disease or symptom severity in children with PANDAS 6.
• Larger prospective studies are needed to improve treatment strategies and classification criteria for PANDAS 3.