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

Treatment of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS)

The treatment of PANDAS requires a multi-component approach including antibiotics for confirmed streptococcal infections, standard OCD treatments, and in selected cases, immunomodulatory therapy. 1

First-Line Treatments

Antibiotic Therapy

• Initial antibiotic treatment is recommended for all newly diagnosed PANDAS cases 2
  • For confirmed Group A Streptococcus (GAS) infection:
    • Preferred: Penicillin (50-75 mg/kg/day in 3-4 doses) or amoxicillin (50-75 mg/kg/day in 2 doses) 3
    • Alternative: Oral clindamycin (40 mg/kg/day in 3 doses) for penicillin-allergic patients 3
  • Duration: Typically 10 days for acute infection

Psychiatric Interventions

• Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) 1, 4
  • Shown to be significantly effective in reducing OCD symptoms and parental stress 4
• Selective serotonin reuptake inhibitors (SSRIs) for persistent OCD symptoms 1

Second-Line Treatments

Prophylactic Antibiotics

• Consider for children with PANDAS who have:
  • Severe neuropsychiatric symptoms
  • Recurrent GAS-associated exacerbations 2
• Options include:
  • Penicillin V (250 mg twice daily)
  • Azithromycin (250 mg 2-3 times weekly) for penicillin-allergic patients

Immunomodulatory Therapy

• Reserved for cases with persistent symptoms despite standard treatments 1
• Options include:
  • Intravenous immunoglobulin (IVIG): 1-2 g/kg divided over 2 days 1
  • Plasma exchange (less commonly used)
  • Corticosteroids for acute symptom flares

Monitoring and Prevention

Infection Surveillance

• Regular monitoring for streptococcal infections in both patient and close contacts 1
• Prompt diagnosis and treatment of intercurrent infections:
  • Streptococcal pharyngitis
  • Sinusitis
  • Influenza

Additional Preventive Measures

• Maintain standard immunization schedule 2
• Ensure adequate vitamin D levels 2
• Enhanced oral hygiene:
  • Regular dental check-ups
  • Soft toothbrush after meals and before sleep
  • Alcohol-free mouthwash rinses 1

Treatment Efficacy and Considerations

• Psychotherapy has shown significant efficacy for OCD symptoms in PANDAS patients 4
• Antibiotic therapy is most effective for managing acute neurological symptoms 4
• Limited evidence supports tonsillectomy or probiotics 2
• Treatment should be initiated promptly during symptom exacerbations to prevent entrenchment of the autoimmune process 1

Diagnostic Considerations

• PANDAS is characterized by:
  • Sudden onset of OCD and/or tic disorders
  • Pre-pubertal symptom onset
  • Episodic course of symptoms
  • Temporal association with GAS infections
  • Associated neurological abnormalities 1
• Laboratory testing may show elevated anti-streptococcal antibodies (ASO, anti-DNase B) in PANDAS 1, 4

The treatment approach should be tailored based on symptom severity, with all confirmed streptococcal infections requiring appropriate antibiotic therapy regardless of neuropsychiatric symptoms. For persistent or severe cases, the combination of antibiotics, psychiatric interventions, and immunomodulatory therapy offers the most comprehensive approach to managing this complex condition.