Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinical diagnosis characterized by the sudden, dramatic onset of obsessive-compulsive disorder (OCD) or severe food restriction in a child. This abrupt change is accompanied by at least two other acute neuropsychiatric symptoms, such as intense anxiety, emotional instability, sleep disturbances, or tics. PANS is thought to arise when an infection or other trigger causes an inflammatory reaction that affects the brain. Treatment requires a comprehensive, multi-faceted approach addressing both the underlying physical cause and the resulting mental health crisis. The integrated strategy aims to reduce neuroinflammation, eliminate the trigger, and manage psychiatric symptoms to promote full recovery.
Eradicating Underlying Infections
The initial phase of PANS management focuses on identifying and eliminating any active infectious triggers. A variety of pathogens, including bacteria, viruses, and fungi, have been associated with PANS onset. Identifying the specific infectious agent guides the choice of antimicrobial therapy, which may involve antibiotics or antivirals.
For cases where a strep infection (Group A Streptococcus or GAS) is suspected or confirmed, an aggressive course of antibiotics is typically prescribed. This approach aims to lower the risk of further neurological injury. Beta-lactam antibiotics (like penicillin or amoxicillin) or macrolides (such as azithromycin) are often used to eradicate the pathogen.
Some antibiotics, such as certain cephalosporins, may also help reduce neuroinflammation. The duration of treatment can vary, often lasting several weeks to fully resolve the neuropsychiatric symptoms.
Immunomodulatory and Anti-Inflammatory Therapies
When symptoms are moderate-to-severe or persist despite treating the underlying infection, therapies aimed at calming the immune system and reducing brain inflammation are used. The core mechanism of PANS is neuroinflammation caused by an immune response that mistakenly targets parts of the brain. These immunomodulatory treatments are reserved for cases where an autoimmune or inflammatory cause is strongly suspected.
Corticosteroids
One common intervention is the use of high-dose corticosteroids, such as oral prednisone, often administered as a short course. Corticosteroids suppress the immune system and quickly reduce inflammation throughout the body, including the brain. A positive response to a steroid course often indicates an underlying inflammatory process is driving the symptoms.
Intravenous Immunoglobulin (IVIG)
For patients with severe symptoms, especially severe food restriction, Intravenous Immunoglobulin (IVIG) may be considered. IVIG is a purified blood product containing pooled antibodies that is thought to “reset” the abnormal immune response by modulating inflammation. This treatment typically involves a high dose administered over one or two days, and repeated doses may be required if symptoms return.
Plasma Exchange (PLEX)
In the most extreme, unresponsive cases, Plasma Exchange (PLEX) may be utilized. This procedure involves removing the patient’s blood plasma, which contains the circulating pathogenic antibodies. The plasma is then replaced with donor plasma or a substitute. Both IVIG and PLEX are complex, intensive therapies used to interrupt the autoimmune attack on the brain and are typically managed by specialists.
Managing Neuropsychiatric Symptoms
While biological treatments address the underlying cause, the resulting psychiatric and behavioral symptoms require simultaneous, direct management to reduce suffering and improve function. The abrupt onset of severe OCD, anxiety, and mood lability is the most debilitating aspect of the condition. Symptomatic treatment is administered regardless of whether the child is receiving antimicrobial or immunomodulatory therapy.
Pharmacological Interventions
Psychiatric medications are often utilized, with Selective Serotonin Reuptake Inhibitors (SSRIs) being the primary choice for managing OCD and anxiety. Children with PANS are often highly sensitive to these medications, necessitating a “start low and go slow” approach. Other medications may be used to address irritability, aggression, or sleep disturbances.
Cognitive Behavioral Therapy (CBT)
Non-pharmacological interventions are equally important, particularly Cognitive Behavioral Therapy (CBT) tailored for PANS patients. A specific form of CBT called Exposure and Response Prevention (ERP) is the standard for treating severe OCD symptoms. ERP involves gradually exposing the child to the feared situation while preventing the compulsive response. Behavioral and psychological support also helps manage severe anxiety through relaxation techniques and supportive counseling.
Comprehensive Long-Term Care
Once the acute episode is managed, sustained long-term care is necessary to maintain remission and prevent future flares. This phase shifts the focus from aggressive treatment to holistic support and careful monitoring. Continuous surveillance for signs of relapse or re-exposure to infectious triggers is an ongoing part of the care plan.
A comprehensive care team is essential, involving pediatricians, neurologists, psychiatrists, and behavioral therapists. Nutritional support and stress management techniques are often incorporated to help stabilize the immune system. Environmental accommodations, such as school support plans, may also be necessary to ease the child’s return to a normal routine.
For children who experience multiple episodes, a low-dose prophylactic antibiotic regimen may be considered to protect against new strep infections. This preventative measure is individualized based on the child’s history and the severity of their relapses. The long-term goal is to fully restore the child’s previous level of functioning.