PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

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What is PANDAS?

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) can affect as many as 1 in 200 children, as estimated by the PANDAS Network.

PANDAS occurs when a streptococcal (GAS) infection triggers a misdirected immune response with central nervous system manifestations. The proposed pathogenesis is controversial, but it is widely accepted that an important component involves GAS antibodies cross-reacting with host antigens in the brain, resulting in encephalitis.

Children aged 5-12 are most susceptible as they have higher levels of exposure to GAS and higher levels of antibodies compared to adults. The usual inciting symptom for PANDAS is a debilitating onset of intense anxiety, mood lability, OCD-like traits and/or tics, associated with a recent strep-A infection. Onset of symptoms is usually within 1-2 weeks after GAS infection but can be up to 6 months later.

Diagnostic Criteria

  1. OCD and/or tic disorder meeting the DSM-5 diagnostic criteria
  2. Pediatric onset
  3. Abrupt onset and episodic course of symptoms
  4. Temporal relation between GAS infection and onset/exacerbation of symptoms
  5. Neurologic abnormalities, such as motoric hyperactivity (fidgeting, difficulty staying seated) and/or choreiform movement (seen during stressed postures but not at rest)

Clinical Course

PANDAS is usually characterized by a “sawtooth” pattern of symptoms, with periods of abrupt exacerbation of symptoms followed by a gradual improvement over weeks to months. These children can also have simultaneous onset of frequent and severe motor/verbal tics. Children with a prior diagnosis of OCD can experience an abrupt onset of severe OCD symptoms resulting in significant impairment within days.

Diagnosis/Management

The diagnosis of PANDAS is clinical once GAS has been confirmed by throat or skin culture, rapid strep test, or a rise in anti-strep antibodies. Antibiotic therapy is initiated to treat a confirmed acute strep infection. Children with PANDAS should be retreated with antimicrobial therapy given the failure rates for penicillin/amoxicillin. Treatment of GAS is associated with resolution of symptoms. Children with OCD and/or tic disorders should receive standard neuropsychiatric treatment regardless of whether PANDAS has been confirmed or not.

 

References

Pichichero, M. E., MD. (2018, June). PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (S. L. Kaplan MD, D. R. Nordli MD, & M. M. Torchia MD, Eds.). Retrieved July 17, 2018, from https://www.uptodate.com/contents/pandas-pediatric-autoimmune-neuropsychiatric-disorder-associated-with-group-a-streptococci?search=PANDAS&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1#H2
Pandas Network. (2017). WHAT IS PANDAS? Retrieved July 17, 2018, from http://www.pandasnetwork.org/understanding-pandaspans/what-is-pandas/

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