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

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

Currently, there is insufficient evidence to recommend routine laboratory testing for Group A Streptococcus (GAS), long-term antistreptococcal prophylaxis, or immunoregulatory therapy for PANDAS, as the concept remains an unproven hypothesis. 1

Current Understanding of PANDAS

• PANDAS is characterized by sudden-onset obsessive-compulsive disorder (OCD) and/or tics following streptococcal infection, hypothesized to involve autoimmune responses cross-reacting with brain tissue 1
• The American Heart Association considers PANDAS an unproven hypothesis that requires further research before specific treatment recommendations can be made 1
• The condition is thought to be similar to Sydenham chorea's autoimmune mechanism but lacks conclusive evidence establishing a causal relationship between GAS infections and neuropsychiatric symptoms 1

Treatment Approaches Based on Available Evidence

Acute Treatment

• For confirmed streptococcal infections in PANDAS patients, appropriate antibiotic therapy should be administered to eradicate the infection 2, 3
  • Amoxicillin/clavulanic acid (10-21 days) has been used in clinical practice for acute treatment 2
  • Penicillin or ampicillin may be alternatives based on susceptibility patterns 1

Prophylactic Treatment

• Long-term antibiotic prophylaxis (similar to rheumatic fever protocols) has been used in clinical practice but lacks strong evidence 2, 3
  • Some clinicians have reported using benzathine benzylpenicillin for prophylaxis 2
  • Clinical improvement has been observed in approximately 75% of PANDAS patients within 3-5 months in observational studies 2

Psychiatric Symptom Management

• Psychotherapy, particularly for OCD symptoms, has shown efficacy in managing neuropsychiatric symptoms 3
• Standard psychiatric treatments for OCD and tics should not be overlooked while the controversy about PANDAS pathophysiology continues 4, 3

Important Considerations and Caveats

• Relapses of neurologic manifestations have been observed in approximately 45% of patients despite prophylactic treatment 2
• The evidence for antibiotic use in PANDAS independent of active infection remains limited and inconclusive 5
• Patient satisfaction appears to correlate with overall clinical improvement rather than specific treatments 4
• Differential diagnosis should include other conditions that may present with similar symptoms, including cerebral folate deficiency which may overlap with some PANDAS/PANS presentations 6

Research Gaps

• Well-designed controlled studies comparing antibiotics with other therapies are needed 5
• Long-term safety and efficacy data for antibiotic prophylaxis in PANDAS are lacking 5
• Studies establishing a definitive causal relationship between GAS infections and neuropsychiatric symptoms are required before specific treatment recommendations can be made 1