What is the appropriate diagnostic and treatment approach for a 23-year-old male presenting with signs and symptoms suggestive of an autoimmune neuropsychiatric disorder, potentially triggered by a streptococcal infection?

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PANDAS in a 23-Year-Old Male: Clinical Presentation and Diagnostic Approach

Critical Age Consideration

PANDAS diagnostic criteria explicitly require prepubertal symptom onset, making this diagnosis highly unlikely in a 23-year-old male presenting with new symptoms. 1, 2 The original PANDAS cohort demonstrated mean age of onset at 6.3 years for tics and 7.4 years for OCD, with all cases occurring in childhood. 1

If Symptoms Began in Childhood (Retrospective Diagnosis)

Cardinal Clinical Features

PANDAS presents with five essential diagnostic criteria that must all be present: 1, 2

  • Abrupt, dramatic onset of obsessive-compulsive disorder (OCD) and/or tic disorder in prepubertal years 1
  • Episodic, relapsing-remitting course with clear exacerbations and remissions 1
  • Temporal association with Group A beta-hemolytic streptococcal (GABHS) infection, documented by positive throat culture, rapid antigen test, or elevated anti-streptolysin O (ASO) and anti-DNase B titers 3, 1
  • Neurological abnormalities including choreiform movements, motor hyperactivity, or tics 1
  • Psychiatric comorbidities during exacerbations: separation anxiety (86-92%), urinary urgency/frequency without infection (42-81%), sleep disruptions (71%), emotional lability, nighttime fears, and cognitive deficits 1, 2

Distinctive Urinary Symptoms

Daytime urinary urgency and frequency without dysuria, fever, or incontinence occurs in 42-81% of PANDAS cases and represents a highly characteristic feature. 3, 2 These symptoms disappear at night, and urinalysis/urine cultures are negative. 3

Diagnostic Workup

Document streptococcal infection through throat culture (rapid antigen and/or culture) and serologic testing (ASO and anti-DNase B titers). 3, 1 In the original prospective study, very high anti-DNase B titers were characteristic. 3

Rule out alternative autoimmune encephalopathies that can present with neuropsychiatric symptoms in young adults: 4

  • Anti-NMDA receptor encephalitis: More common in young adults, presents with acute psychiatric symptoms, seizures, and dyskinetic movements 5
  • Neuropsychiatric systemic lupus erythematosus (NPSLE): Requires comprehensive evaluation including MRI with gadolinium, CSF analysis, antiphospholipid antibodies, and exclusion of infection 6, 7

Neuropsychological Assessment

Expect relative deficits in frontostriatal network functions even after acute symptom resolution: 8

  • Attentional regulation and inhibitory control difficulties 8
  • Reduced processing speed and graphomotor skills 8
  • Normal intellectual functioning but impaired reading/math fluency 8
  • Persistent anxiety, depression, inattention, and social skills deficits requiring ongoing intervention 8

Treatment Approach (If Childhood-Onset PANDAS Confirmed)

Acute Management

Treat documented GABHS infection with amoxicillin/clavulanic acid for 10-21 days. 4 In prospectively identified cases, OCD symptoms promptly disappeared with appropriate antibiotic therapy at the sentinel episode. 3

Long-Term Prophylaxis

Administer benzathine benzylpenicillin prophylaxis for at least 5 years to prevent streptococcal reinfections and neuropsychiatric relapses. 4 This regimen, similar to acute rheumatic fever prophylaxis, resulted in improvement in 75% of PANDAS patients within 3-5 months, though 45% experienced infection-related relapses during long-term follow-up. 4

Monitoring Strategy

Obtain prospective throat cultures after treatment to distinguish true infection from GABHS carrier state. 3 Recurrence of OCD symptoms associated with documented acute GABHS infection and response to antibiotics confirms active disease rather than carrier status. 3

Critical Pitfalls

Do not diagnose PANDAS in adults with new-onset symptoms—consider anti-NMDA receptor encephalitis, NPSLE, or other autoimmune encephalopathies instead. 5, 7 The prepubertal onset criterion is fundamental to PANDAS diagnosis. 1, 2

Do not confuse PANDAS with PANS (Pediatric Acute-onset Neuropsychiatric Syndrome)—PANS has similar presentation but lacks documented streptococcal association and may be triggered by Mycoplasma pneumoniae (42.3%) or Epstein-Barr virus (19.2%). 4 PANS patients showed improvement after 6-12 months versus 3-5 months for PANDAS. 4

Early diagnosis is essential—delayed recognition increases risk of disabling chronic neurologic sequelae. 4

References

5
Guideline

Encefalitis Anti-Receptor NMDA: Diagnóstico y Manejo

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

6
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

7
Guideline

Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) Clinical Presentation and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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