Untreated Childhood PANDAS: Expected Symptoms at Age 26
If PANDAS went undiagnosed and untreated in childhood, a 26-year-old would most likely present with chronic obsessive-compulsive symptoms, residual tics, and potentially neuropsychiatric features that have persisted or evolved into adult OCD and anxiety disorders, though the evidence for adult PANDAS remains limited and controversial.
Critical Context About PANDAS in Adults
The fundamental challenge here is that PANDAS remains "an unproven hypothesis" according to the American Heart Association 1, 2, 3. The condition is defined by prepubertal onset as one of its five essential diagnostic criteria 2. However, there is at least one documented case suggesting poststreptococcal autoimmune neuropsychiatric disease can occur in adults 4.
Most Likely Clinical Presentation at Age 26
Persistent Obsessive-Compulsive Features
- The core OCD symptoms that emerged acutely in childhood would likely have evolved into chronic, treatment-resistant OCD 5, 6
- Common obsessions would include contamination fears, preoccupation with germs, and ritualistic behaviors like hand washing 7
- These symptoms may have waxed and waned over the years, particularly if the patient experienced recurrent streptococcal infections during adolescence 7
Residual Tic Disorders
- Tics that began during the acute PANDAS episode may persist into adulthood, though they often diminish in severity 2, 3
- Motor and vocal tics characteristic of Tourette's syndrome may be present 4
Neuropsychiatric Comorbidities
- Generalized anxiety and depression are common sequelae, as untreated OCD symptoms create significant functional impairment 5
- Attention difficulties and hyperactivity that emerged during acute episodes may have persisted 8
- Cognitive-behavioral patterns established during childhood would be deeply ingrained by age 26 5
Unique Urinary Symptoms
- Daytime urinary urgency and frequency without infection were notably common in PANDAS patients (58% in one series) and may persist as a chronic symptom 7
- These symptoms characteristically disappear at night and occur without dysuria or positive urine cultures 7
Key Distinguishing Features from Primary OCD
The main difference between untreated PANDAS and primary OCD would be:
- History of abrupt, dramatic onset in childhood (rather than gradual development) 2, 3
- Episodic course with exacerbations potentially linked to infections 2, 7
- Associated neurological abnormalities like choreiform movements or motor hyperactivity that may have been present initially 2, 8
- Temporal relationship to streptococcal infections in the patient's history 7
Evidence Limitations and Clinical Reality
The single case report of adult-onset PANDAS-like illness at age 25 suggests the autoimmune process can occur in adults 4. This patient had elevated antistreptococcal antibodies, D8/17 lymphocytes, antistriatal antibodies, and abnormal MRI findings 4. However, this represents extremely limited evidence.
Most experts now use the broader term PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) rather than PANDAS, recognizing that multiple infectious and inflammatory triggers beyond streptococcus may be involved 8, 6. The shift away from PANDAS as a distinct entity reflects ongoing controversy about its validity as a separate diagnosis 6.
Treatment Implications at Age 26
- Standard OCD treatment with SSRIs and cognitive-behavioral therapy would be first-line, as these remain the recommended approaches even for confirmed PANDAS 5, 6
- Antibiotics would only be indicated if there is evidence of active streptococcal infection 1, 3
- Long-term antistreptococcal prophylaxis is not recommended 1, 3
- Immunomodulatory therapies (IVIG, plasma exchange) are not recommended as routine treatment 1, 3
Common Pitfall to Avoid
Do not retrospectively diagnose PANDAS in an adult based solely on elevated streptococcal antibody titers, as these are common in the general population and do not confirm the diagnosis without meeting all five clinical criteria during childhood 2. The diagnosis requires documented prepubertal onset with all characteristic features present simultaneously 2.