What are the diagnosis criteria, treatment options, and controversies surrounding Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) infections?

From the Guidelines

The current state of knowledge dictates that the concept of PANDAS should be considered only as a yet-unproven hypothesis, and therefore, routine laboratory testing for GAS to diagnose, long-term antistreptococcal prophylaxis to prevent, or immunoregulatory therapy to treat exacerbations of this disorder is not recommended 1.

Diagnosis and Treatment

The diagnosis of PANDAS requires a comprehensive approach, considering the presence of obsessive-compulsive disorder (OCD) or tic disorder, prepubertal symptom onset, sudden onset and episodic course, temporal association with Group A Streptococcal (GAS) infection, and neurological abnormalities.

• Treatment typically involves a multi-faceted approach, starting with antibiotics like penicillin or amoxicillin for 10-14 days to eradicate streptococcal infection.
• For psychiatric symptoms, cognitive behavioral therapy is first-line, with selective serotonin reuptake inhibitors (SSRIs) like sertraline (25-200 mg daily) or fluoxetine (10-80 mg daily) added for moderate to severe OCD symptoms.

Controversy and Recent Research

The controversy surrounding PANDAS stems from limited evidence supporting the causal relationship between strep infections and neuropsychiatric symptoms, inconsistent diagnostic criteria application, and debate about the efficacy of immunomodulatory treatments 1.

• Recent research has shifted from PANDAS to a broader disorder — pediatric acute-onset neuropsychiatric syndrome — which is characterized by the sudden onset of obsessive–compulsive symptoms that can occur in response to a range of infections and other insults.
• Many medical organizations remain skeptical about PANDAS as a distinct clinical entity, leading to variations in recognition and treatment approaches across different healthcare systems.

Clinical Approach

In clinical practice, a cautious approach is recommended, prioritizing the treatment of underlying infections and managing psychiatric symptoms with established therapies, while avoiding unnecessary and unproven treatments 1.

• A thorough diagnostic evaluation and a comprehensive treatment plan should be individualized for each patient, taking into account the latest research and clinical guidelines.

From the Research

Diagnosis Criteria

• The diagnosis of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) and PANS (Pediatric Acute-Onset Neuropsychiatric Syndrome) is based on the presence of acute-onset obsessive-compulsive disorder (OCD) or other neuropsychiatric symptoms, such as anxiety, depression, and irritability, following a streptococcal infection or other infectious trigger 2, 3.
• The clinical features of PANDAS and PANS include a range of neurological and psychiatric symptoms, such as tics, anxiety, depression, and irritability, with no significant difference between the two groups 4.

Treatment

• The treatment of PANDAS and PANS typically involves a combination of psychiatric and behavioral interventions, such as cognitive-behavioral therapy (CBT), and pharmacological interventions, such as antidepressants and antipsychotics 2, 4.
• Antibiotics, such as penicillin and azithromycin, may be used to treat the underlying streptococcal infection or other infectious trigger, and immunomodulatory therapies, such as intravenous immunoglobulin (IVIG), may be used to modulate the immune system's response to the infection 3, 5.
• Psychotherapy, particularly CBT, has been shown to be effective in reducing symptoms of OCD and other neuropsychiatric symptoms in patients with PANDAS and PANS 4.

Controversy

• There is ongoing controversy and debate regarding the diagnosis and treatment of PANDAS and PANS, with some clinicians and researchers questioning the existence of these conditions as distinct entities 3, 5.
• The use of antibiotics and immunomodulatory therapies in the treatment of PANDAS and PANS is also a topic of debate, with some studies suggesting that these treatments may be effective in reducing symptoms, while others have raised concerns about the potential risks and benefits of these treatments 3, 5.
• Barriers to treatment, such as clinician lack of awareness and skepticism, overdependence on diagnostic testing, and out-of-pocket expenses, can also contribute to delays in diagnosis and treatment of PANDAS and PANS 6.