Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a complex condition characterized by a sudden, dramatic onset of debilitating psychiatric and neurological symptoms in children, defined by the abrupt appearance of obsessive-compulsive disorder (OCD) or severely restricted food intake. It is often accompanied by other symptoms like anxiety, mood changes, and motor abnormalities. PANS is thought to be triggered by an infection, which can include various pathogens, leading to an autoimmune response that affects the brain. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is a subset of PANS, specifically linked to a preceding Streptococcal infection. Recovery requires a multi-faceted treatment strategy addressing the underlying biology and resulting behavioral changes.
Understanding the Diagnostic Process
PANS is a clinical diagnosis, meaning there is no single laboratory test to confirm its presence. A diagnosis is established by careful observation of a child’s medical history, current symptoms, and the acute nature of their onset. The clinician must first confirm the presence of an abrupt, dramatic onset of either obsessive-compulsive symptoms or a severe restriction of food intake.
The sudden onset must be accompanied by at least two additional neuropsychiatric symptoms from a specified list of categories. These secondary symptoms include:
- Anxiety
- Emotional lability
- Depression
- Irritability
- Behavioral regression
- Sudden decline in school performance
- Sensory abnormalities
- Somatic issues (e.g., urinary frequency and sleep disturbances)
The evaluation involves ruling out other potential neurologic or medical conditions, leading to PANS often being referred to as a diagnosis of exclusion. Laboratory tests may be ordered to identify an active or recent infection, such as Streptococcus, or markers of immune system dysfunction, but the diagnosis remains fundamentally rooted in the clinical picture.
Targeting the Underlying Inflammation and Infection
Treatment for PANS focuses first on resolving any active infection and then modulating the resulting immune system dysregulation. If a bacterial infection is identified, a course of antibiotics is often administered to eradicate the pathogen and prevent further immune triggering. In cases linked to a viral or other non-bacterial trigger, antivirals may be considered, though the focus quickly shifts to dampening the neuroinflammation.
For managing the acute inflammatory response, anti-inflammatory medications are frequently used, starting with Nonsteroidal Anti-inflammatory Drugs (NSAIDs) for milder presentations. If symptoms are moderate to severe, corticosteroids, such as oral prednisone or intravenous methylprednisolone, are often prescribed for a short burst to rapidly reduce inflammation. Corticosteroids suppress the immune system’s overreaction, but require careful monitoring due to potential side effects.
In more severe and debilitating cases, or those unresponsive to initial anti-inflammatory treatments, immunomodulatory therapies are considered. Intravenous Immunoglobulin (IVIG) involves infusing a pooled product of antibodies from healthy donors to help reset the patient’s faulty immune response. An alternative intensive therapy is therapeutic plasma exchange, or plasmapheresis, which involves filtering the patient’s blood to remove pathogenic antibodies and replacing the plasma with an albumin solution. Plasmapheresis is generally reserved for patients with extreme impairment due to its invasive nature.
Managing Neuropsychiatric Symptoms
Even as the underlying inflammation is addressed, the resulting neuropsychiatric symptoms like profound anxiety and OCD can persist and require specific treatment. Pharmacological interventions are used to manage the severity of these symptoms, allowing the child to regain functional capacity. Selective serotonin reuptake inhibitors (SSRIs) are the primary medication class used to treat the obsessive-compulsive and anxiety symptoms associated with PANS.
SSRI treatment must be initiated at a very low dose and titrated slowly, as children with PANS can exhibit heightened sensitivity, sometimes experiencing paradoxical agitation or increased anxiety. Fluoxetine and sertraline are among the SSRIs commonly prescribed for pediatric OCD. Other psychotropic medications may be necessary to address specific co-occurring symptoms, such as irritability, severe aggression, or profound sleep disturbances.
Complementing medication, a specialized form of psychotherapy known as Cognitive Behavioral Therapy (CBT) is used for managing behavioral symptoms. Specifically, Exposure and Response Prevention (ERP) is the evidence-based behavioral treatment for OCD. ERP involves gradually exposing the child to their feared trigger while preventing them from performing the compulsive ritual or avoidance behavior. ERP is necessary to unlearn ingrained behavioral patterns of OCD and provide the child with long-term coping tools.
Comprehensive Support and Environmental Strategies
Beyond medical and psychiatric treatment, the child’s environment and daily life must be adapted to support recovery and reduce stress. School accommodations are often necessary because the sudden onset of symptoms like handwriting difficulties, frequent urination, and cognitive decline significantly impacts a child’s ability to learn. An Individualized Education Program (IEP) or a 504 Plan can provide necessary supports.
A 504 Plan focuses on accommodations that grant equal access to education, such as allowing extra time for assignments, preferential seating, or providing a pass for frequent bathroom breaks. An IEP is required when a child needs specialized instruction or modifications to the curriculum, often when symptoms are severe or cause significant developmental regression. Accommodations should also address sensory sensitivities and fine motor skill decline, perhaps by allowing the child to type assignments instead of writing them by hand.
At home, managing behavioral crises requires parents to employ de-escalation strategies and maintain a calm, structured environment. Sleep hygiene is important, as sleep disturbances are common, and consistent rest supports brain healing. Nutritional support is often needed, especially for children with severely restricted food intake, which may necessitate working with a feeding specialist. Addressing the holistic needs of the child and providing support for the family system is essential for long-term recovery.