Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the sudden, dramatic onset of obsessive-compulsive disorder (OCD) or severely restricted eating. This is accompanied by other neuropsychiatric symptoms like anxiety, mood changes, and tics. These symptoms are often linked to an underlying inflammatory process in the brain, necessitating specialized medical attention. PANS treatment is individualized and multi-faceted, requiring a coordinated medical team to address the infection, the immune response, and the resulting neuropsychiatric symptoms.
Addressing Underlying Infections
The initial and foundational step in managing PANS involves identifying and eliminating any active infectious trigger responsible for the immune system misdirection. While Group A Streptococcus (GAS) is a trigger in the subset condition PANDAS, PANS can be incited by various pathogens, including Mycoplasma pneumoniae, Lyme disease, and viruses. Treatment begins with antimicrobial agents, such as antibiotics or antivirals, targeting the suspected or confirmed infectious agent.
A trial course of antibiotics may be recommended even if an active infection is not documented, as a hidden or recently resolved infection could still drive the inflammatory response. Common antibiotics include azithromycin, which offers anti-inflammatory properties, or beta-lactam antibiotics like penicillin or amoxicillin. Complete eradication of the pathogen is the primary goal, and some patients require prolonged courses of medication to prevent symptom relapse.
Calming the Immune System Response
The core pathology of PANS involves a misdirected immune response causing neuroinflammation. This requires targeted immunomodulatory therapies, particularly in severe cases. These treatments aim to dampen the brain inflammation driving the acute onset and severity of neuropsychiatric symptoms. Immunomodulatory therapies are reserved for patients with severe, disabling symptoms who have not responded adequately to antimicrobial treatment alone.
Corticosteroids, such as prednisone, may be administered for a short duration (a burst) to rapidly reduce acute inflammation during a severe symptom flare. Steroids suppress the immune system and decrease the entry of inflammatory cells into the central nervous system. This acute therapy provides temporary relief, allowing other longer-acting treatments to take effect.
Intravenous Immunoglobulin (IVIG) infuses pooled antibodies from healthy donors into the patient. The mechanism of IVIG is complex, but it is thought to neutralize pathogenic autoantibodies and suppress the production of new antibodies by the patient’s immune cells. IVIG is considered for children with severe and refractory symptoms and is administered in a specialized medical setting.
Plasma Exchange (Plasmapheresis) is an intensive immunomodulatory option that physically removes the patient’s plasma containing harmful autoantibodies and inflammatory mediators, replacing it with a substitute solution. Plasmapheresis is an invasive and resource-intensive procedure, reserved for the most severe cases where a rapid reduction of circulating antibodies is necessary. Other immunosuppressive medications may be considered for highly treatment-resistant cases under the guidance of a specialist physician.
Strategies for Neuropsychiatric Symptom Management
Managing the severe neuropsychiatric symptoms is necessary to reduce suffering and improve daily function while the infection and inflammation are being addressed. These symptoms, including severe OCD, anxiety, emotional lability, and tics, require a combination of pharmacological and behavioral interventions. The goal is to provide symptom relief while the underlying neuroinflammation is treated.
Pharmacological support often involves selective serotonin reuptake inhibitors (SSRIs) to manage obsessive-compulsive symptoms and anxiety. PANS patients can exhibit a unique sensitivity to these medications, sometimes experiencing paradoxical effects like increased agitation or worsening of symptoms. Clinicians begin with a significantly reduced starting dose—often one-quarter to one-half the typical dose—and increase it slowly, monitoring closely for adverse behavioral activation.
Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP) for OCD, is a first-line psychological treatment. ERP gradually exposes the child to anxiety triggers while preventing the compulsive response, which helps to rewire the brain’s fear response. For CBT/ERP to be effective, it must be tailored to the child’s current symptom severity, as intense flares may prevent engagement. Other psychotropic medications, such as anti-anxiety agents, low-dose antipsychotics, or medications for tics, may be used as adjuncts to manage severe aggression, rage, or persistent tics.
Academic and Family Support Strategies
Practical support for the child and family is an indispensable component of PANS treatment, focusing on maintaining quality of life and reducing environmental stress. Academic accommodations are frequently needed due to symptoms like learning regression, attention difficulties, and fine motor issues. Schools should implement flexible plans, such as a 504 Plan or an Individualized Education Program (IEP), to address the fluctuating nature of the illness.
These plans may include provisions for reduced academic workload, extended time for assignments, preferential seating, or temporary home instruction during severe flares. Educators must understand that symptoms are medically driven, not behavioral choices, and academic pressure should be minimized during symptom exacerbations. Families require significant psychoeducation to understand the syndrome and learn effective coping strategies.
Parents benefit from strategies for managing rage episodes without accommodating the child’s compulsions or fears, which can inadvertently reinforce them. Validating the child’s distress while maintaining boundaries helps reduce family stress and creates a stable environment. Environmental modifications, such as minimizing exposure to infectious triggers or providing sensory supports, contribute to improving the child’s overall function and quality of life.