What is the treatment for Pediatric Acute-onset Neuropsychiatric Syndrome (PANS)?

Treatment of Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)

The treatment of PANS requires a three-pronged approach targeting infection, inflammation, and neuropsychiatric symptoms, with antibiotics and anti-inflammatory medications forming the cornerstone of effective therapy.

Understanding PANS

PANS is characterized by the sudden, dramatic onset of obsessive-compulsive disorder (OCD) and/or restricted eating accompanied by at least two additional neuropsychiatric symptoms. Unlike PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections), which is specifically associated with Group A Streptococcus infections, PANS can be triggered by various infections or inflammatory reactions.

Treatment Algorithm

1. Antimicrobial Treatment

• Initial Approach: All newly diagnosed PANS cases should receive an initial course of anti-streptococcal treatment 1

• Antibiotic Selection:

  • Broad-spectrum antibiotics are generally more effective than narrow-spectrum options
  • Longer courses (>30 days) produce better results, with up to 52% of patients achieving a "very effective" response 2
  • Particularly important for patients with laboratory-confirmed immune deficiency 2

• Prophylaxis: Consider chronic secondary antimicrobial prophylaxis for children with severe neuropsychiatric symptoms or recurrent exacerbations 1

2. Anti-inflammatory Therapy

• First-line options:

  • NSAIDs (such as ibuprofen) are at least "somewhat effective" for most patients 2
  • Consider more aggressive anti-inflammatory treatment for moderate to severe cases

• Immunomodulatory therapy:

  • Intravenous immunoglobulin (IVIG) is effective in 89% of treated patients, though 18% experience non-sustained response 2
  • Best results with IVIG are seen in immune-deficient patients receiving doses of at least 0.8 g/kg on a regular basis 2

3. Psychiatric/Behavioral Interventions

• Psychotherapy:

  • Cognitive behavioral therapy (CBT) is at least somewhat effective for the majority of treated patients 2
  • Family counseling is rated highly appropriate by parents 3
  • Psychotherapy significantly relieves OCD symptoms and reduces stress in patients and parents 4

• Psychotropic medications:

  • SSRIs are commonly used but have limited effectiveness (only 44% find them "somewhat" to "very effective") 2
  • May require marked reduction of initial treatment doses compared to standard psychiatric practice 5
  • Consider as adjunctive therapy rather than primary treatment

Additional Considerations

• Monitoring for infections:

  • Vigilance for streptococcal pharyngitis or dermatitis in the patient and close contacts
  • Prompt diagnosis and treatment of intercurrent infections (sinusitis, influenza, etc.) 1

• Supportive care:

  • Maintain standard immunizations
  • Ensure adequate vitamin D levels 1
  • Consider lifestyle modifications, which are rated highly appropriate by parents 3

• Treatments with limited evidence:

  • Adenotonsillectomy and probiotics have shown limited utility 1
  • Deep brain stimulation and transcranial magnetic stimulation are rated as inappropriate by parents 3

Treatment Response Monitoring

• Regular clinical assessment of both neuropsychiatric symptoms and underlying infectious/inflammatory processes
• Adjust treatment based on symptom severity, with more aggressive approaches for severe or treatment-resistant cases
• Be alert for exacerbations that may require intensification of therapy

Pitfalls to Avoid

• Focusing solely on psychiatric symptoms without addressing underlying infection/inflammation
• Relying exclusively on psychotropic medications, which show limited effectiveness as monotherapy
• Delaying antimicrobial treatment while awaiting definitive diagnosis
• Discontinuing treatment prematurely, as some patients require longer courses for sustained improvement

The evidence suggests that patients with PANS benefit most from treatment approaches that aggressively target both the infectious triggers and inflammatory responses, while simultaneously addressing psychiatric symptoms through appropriate behavioral interventions.