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

From the Guidelines

The PANDAS hypothesis should be considered only as a yet-unproven hypothesis and not used to guide clinical decision-making for pediatric patients with obsessive-compulsive disorder or tic disorders. The current state of knowledge on PANDAS is based on limited evidence, and the American Heart Association does not recommend routine laboratory testing for GAS to diagnose, long-term antistreptococcal prophylaxis to prevent, or immunoregulatory therapy to treat exacerbations of this disorder [ 1 ].

Key Points

• The PANDAS hypothesis proposes that a subset of patients with obsessive-compulsive and tic disorders produce autoimmune responses that cross-react with brain tissue in response to a GAS infection [ 1 ].
• 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 [ 1 ].
• The recognition of PANDAS was given impetus by early work that demonstrated the presence of obsessive-compulsive symptoms in Sydenham chorea, which is caused by childhood streptococcal infection [ 1 ].

Clinical Implications

• The committee does not recommend routine laboratory testing for GAS to diagnose, long-term antistreptococcal prophylaxis to prevent, or immunoregulatory therapy to treat exacerbations of this disorder [ 1 ].
• Clinicians should exercise caution when considering a diagnosis of PANDAS and instead focus on evidence-based treatments for obsessive-compulsive disorder and tic disorders [ 1 ].
• Further research is needed to establish a causal relationship between PANDAS and GAS infections before considering it a proven hypothesis [ 1 ].

From the Research

Definition and Characteristics of PANDAS

• PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) is a subtype of acute-onset obsessive-compulsive disorder (OCD) thought to be caused by an autoimmune response to group A streptococcal infection 2.
• The five clinical characteristics that define the PANDAS subgroup are the presence of OCD and/or tic disorder, prepubertal age of onset, abrupt onset and relapsing-remitting symptom course, association with neurological abnormalities during exacerbations, and a temporal association between symptom exacerbations and a Group-A beta-hemolytic streptococcal (GAS) infection 3.

Treatment Options for PANDAS

• Various treatment options exist, including tonsillectomy, antibiotic treatment/prophylaxis, intravenous immunoglobulin (IVIG), and psychiatric medications/therapy 4.
• Antibiotics have been used to treat patients with PANDAS, with some evidence suggesting their efficacy in reducing neuropsychiatric symptoms 5.
• Cognitive-behavioral therapy (CBT) has also shown benefit in PANDAS patients 4.
• IVIG has been studied as a potential treatment, but more investigation is needed to fully understand its benefits and risks 4.

Research and Evidence

• The literature on treatment of PANDAS is diverse, and clinical consensus regarding optimal treatment strategy is lacking 2.
• Rigorously conducted research regarding treatments for PANDAS is scarce, and published studies have a high risk of bias 2.
• Further research is needed to investigate promising treatment strategies for PANDAS and other variants of OCD with proposed autoimmune etiology 2, 5.