PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections)

  • Medical Author: Paulo R. Pina, MD, MPH
  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Just a Sore Throat or Strep Slideshow

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) facts

  • PANDAS is an acronym for "pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections."
  • It is a fairly recently described disorder (1990s).
  • An autoimmune response to a streptococcal infection is the leading theory as to the cause of PANDAS.
  • It is diagnosed if there is a history of abrupt development of a number of neuropsychiatric symptoms associated with a group A streptococcal (the type of bacteria causing strep throat) infection.
  • Medication and cognitive behavioral therapy (CBT) are the primary treatments for PANDAS.

What is PANDAS?

PANDAS is an acronym that refers to "pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections." It is diagnosed clinically after a patient develops a number of behavioral and physical symptoms following a streptococcal infection (for example, strep throat, sinusitis, cellulitis, or scarlet fever).

Is PANDAS common?

PANDAS is a rare condition. It is believed that approximately one in 2,000 children are affected, though the diagnosis may be overlooked due to some of the common symptoms associated with the disease. In fact, there are some researchers who recommend categorizing PANDAS as a subset of other disorders, which includes similar neuropsychiatric symptoms called CANS (childhood acute neuropsychiatric symptoms) or PANS (pediatric acute-onset neuropsychiatric syndrome).

What is the history of PANDAS?

PANDAS was described in the late 1990s after investigators identified a subgroup of children who developed a sudden onset of obsessive-compulsive disorder (OCD) symptoms, vocal and motor tics, and other behavioral changes. They identified that there was a common association in these children, and that was identified as a recent or active infection with a beta-hemolytic Streptococcus, the bacteria that causes strep throat. Researchers also identified a number of other infectious agents, known to cause significant auto-inflammatory reactions associated with neuropsychiatric symptoms, including influenza, varicella, and even Borrelia burgdorferi (Lyme disease), but the diagnosis of PANDAS is limited to streptococcal infections.

Children with strep throat

What Are the Potential Complications of Strep Throat?

The possible complications of strep throat include

  • acute rheumatic fever,
  • glomerulonephritis,
  • otitis media (middle ear infection),
  • Toxic shock syndrome (a rare but severe complication which may result in the failure of multiple organs and may thus be fatal),
  • Peritonsillar abscess or retropharyngeal abscess (walled off infection containing GAS bacteria and pus which may encroach upon the structures in the back of the throat or invade and rupture into deeper structures which may ultimately be fatal), and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep)

What causes PANDAS?

Consensus opinion is that PANDAS is in part caused by an autoimmune response to a strep infection. Streptococcus is known to be associated with a number of immune-related disorders, including rheumatic fever, scarlet fever, and acute glomerulonephritis (a kidney disorder). The strep molecules are known to hide from the host immune system by mimicking host cells. Ultimately, the immune system recognizes the foreign cells, and the antibodies produced attack the bacterium, and unfortunately, some of the host's own cells are attacked as well due to cross-reactivity. In some situations, these antibodies attack brain cells, causing OCD, tics, and the other symptoms frequently observed in PANDAS patients.

What are risk factors for PANDAS?

Multiple risk factors may play a role in the development of PANDAS, including recurrent group A streptococcal infections, family history of rheumatic fever, and the mother's history of having an autoimmune disease. PANDAS is also more common in boys and prepubertal children.

What are symptoms and signs of PANDAS?

PANDAS symptoms are similar to those of obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), and motor or verbal tics. Other symptoms include separation anxiety (the child has difficulty separating from the parent), mood changes, changes in handwriting, bedwetting or change in urinary frequency, and sleep disturbances. Symptoms tend to appear suddenly, and the recovery period is variable. Often the symptoms may worsen during streptococcal infections and improve in between.

What type of doctors treat PANDAS?

Most children will first be seen by their pediatrician when symptoms develop. Further management requires referral to a psychiatrist or other mental-health professional who can prescribe medication and provide cognitive behavioral therapy. Other physicians that may aid in the management of PANDAS include a pediatric neurologist or behavioral developmental specialist.

How do health-care professionals diagnose PANDAS?

PANDAS is diagnosed clinically. That means that it depends more on history and physical examination rather than other specific studies. The following summarizes the five criteria used to diagnose PANDAS:

  1. Presence of obsessive-compulsive disorder (OCD) and/or a tic disorder, ADHD symptoms, or oppositional behaviors
  2. Abrupt onset and/or symptoms vary in intensity
  3. Association with neurological abnormalities, including motor hyperactivity, or abnormal movements, such as choreiform movements (involuntary jerky movements), other combinations of neuropsychiatric symptoms, such as anxiety, emotional lability, bedwetting, or other regressive behaviors (temper tantrums), personality changes and deterioration in math skills and handwriting
  4. Onset of symptoms from age 3 years to puberty
  5. Association with group A beta-hemolytic streptococcal infection (the bacteria that causes strep throat) either by culture or other evidence of infection, such as scarlet fever or by laboratory test evidence

As mentioned above, there are five criteria used to diagnose the disorder and must include the sudden onset of OCD, tics, ADHD, or a rapid worsening of existing symptoms. To make the diagnosis, one also needs evidence of a recent or active strep infection either by throat culture or by antibody testing for Streptococcus (for example, antistreptolysin O or antideoxyribonuclease B antibodies). A onetime measurement of antibodies is not sufficient for the diagnosis; these antibodies should be measured at two different times (four to six weeks apart) to detect a rise in levels. Along with the clinical diagnosis, it is important to be sure that there is not some other reason for the symptoms, and additional testing might be performed for that reason. In fact, distinguishing PANDAS from Tourette's syndrome (a common tic disorder), OCD, or Sydenham chorea (a movement disorder associated with rheumatic fever also caused by Streptococcus) is not always a simple task.

What is the treatment for PANDAS?

First-line treatments for PANDAS include cognitive behavioral therapy (CBT) and medication, depending on the breadth and severity of symptoms. Currently, the primary medical therapy is focused on controlling the OCD symptoms, and therefore selective serotonin reuptake inhibitor (SSRI) medications are frequently used (fluoxetine [Prozac] and others). The other more acute measure in treating PANDAS is treating the strep infection associated with the symptoms. Antibiotics are the treatment of choice to eradicate an active strep throat infection. Your doctor may prescribe penicillin, amoxicillin (Amoxil), azithromycin (Zithromax), or another antibiotic. For severe and refractory symptoms, the use of other treatments aimed at controlling the immune response have been studied and found to be effective. These include the use of intravenous immunoglobulin, steroids, and plasmapheresis (plasma exchange therapy, in which blood is withdrawn from an individual and the liquid portion is removed and replaced and the blood is transfused back into the individual). For both treatments, the "offending" antibodies are removed. Steroids are less effective, because, although symptoms decrease during the treatment, they return soon after stopping the drug. More studies are needed to be able to recommend immune-modulating therapies without hesitation.

What are complications of PANDAS?

PANDAS has not been associated with the development of heart issues as seen in children with rheumatic fever. Untreated or unrecognized PANDAS may increase the risk of having OCD and tic disorder into adulthood.

What is the prognosis of PANDAS?

Though some children completely recover from PANDAS, there are some who develop persistent neuropsychiatric symptoms or develop worsening symptoms after each strep infection. It is not currently possible to predict which children will be affected or how severely. The mainstay of therapy is to decrease the OCD, tics, or other behaviors that might interfere with daily life and school.

Is it possible to prevent PANDAS?

For those children diagnosed with PANDAS, there is some evidence that prophylactic antibiotics may play a role in preventing the development of strep infections and therefore the worsening of symptoms. However, there are side effects associated with daily antibiotic treatment, including diarrhea and the development of antibiotic resistance. More studies need to be performed to be sure that the preventive treatment is truly effective. Surgical removal of the tonsils and adenoids has not shown to be effective in preventing PANDAS and is thus not recommended.

REFERENCES:

Murphy, T., et al. "Pediatric Acute-Onset Neuropsychiatric Syndrome." Psychiatric Clinics of North America 37 (2014): 353-374.

Singer, H., et al. "Moving from PANDAS to CANS." Journal of Pediatrics 160.5 May 2012: 725-731.

Swedo, S.E., et al. "From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS." Pediatric & Therapeutics 2.2 (2012).

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Reviewed on 9/7/2016
References
REFERENCES:

Murphy, T., et al. "Pediatric Acute-Onset Neuropsychiatric Syndrome." Psychiatric Clinics of North America 37 (2014): 353-374.

Singer, H., et al. "Moving from PANDAS to CANS." Journal of Pediatrics 160.5 May 2012: 725-731.

Swedo, S.E., et al. "From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS." Pediatric & Therapeutics 2.2 (2012).

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