Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections, known as PANDAS, is a condition characterized by a sudden and dramatic onset of neuropsychiatric symptoms in children. It involves the immune system inadvertently impacting brain function following specific triggers.
What is PANDAS?
PANDAS is an autoimmune disorder where the body’s immune system mistakenly attacks its own healthy tissues. In PANDAS, this misdirected immune response specifically targets parts of the brain, particularly the basal ganglia, following a Group A Streptococcal (GAS) infection, such as strep throat.
The underlying mechanism involves molecular mimicry. Antibodies produced to fight strep bacteria can sometimes recognize and attack similar-looking proteins in the brain’s basal ganglia. This cross-reaction leads to inflammation and dysfunction in this brain region, which regulates movement, emotions, and behavior.
Recognizing the Signs
PANDAS symptoms have an abrupt onset, often appearing “overnight” or within days of a strep infection. These can include obsessive-compulsive disorder (OCD)-like behaviors, such as repetitive thoughts or actions, and motor or vocal tics. Children may develop new or worsened tics like eye-blinking, head-jerking, or vocalizations such as grunting or throat clearing.
Beyond OCD and tics, children with PANDAS frequently experience other symptoms. These include:
Significant anxiety, manifesting as heightened fear, panic attacks, or severe separation anxiety.
Emotional lability, including rapid mood swings, irritability, and aggression.
Developmental regression, such as a decline in handwriting or a return to younger behaviors like bedwetting.
Sensory sensitivities, where simple touches or sounds feel overwhelming.
Sleep disturbances.
The symptoms often fluctuate, with periods of improvement followed by exacerbations.
How PANDAS is Identified
PANDAS is a clinical diagnosis, as no single laboratory test can definitively confirm it. Healthcare providers rely on specific diagnostic criteria, a thorough medical history, and physical examination. Criteria include the presence of obsessive-compulsive disorder or a tic disorder, with symptom onset between 3 years of age and puberty.
Other diagnostic criteria include:
An episodic course of symptom severity, with acute exacerbations.
A temporal association with a Group A Streptococcal infection, meaning symptoms appear or worsen following a documented strep infection.
The presence of neurological abnormalities during symptom flares, such as unusual jerky movements or motor hyperactivity.
While lab tests like throat swabs or blood tests for antistreptolysin-O (ASO) or anti-DNase B titers can confirm a recent or current strep infection, these tests do not directly diagnose PANDAS but rather provide evidence of a strep exposure.
Treatment Strategies
Treatment for PANDAS aims to address the underlying strep infection, reduce brain inflammation, and manage neuropsychiatric symptoms. A primary intervention involves antibiotics to eradicate any remaining Group A Streptococcal infection. Treating the infection can help reduce PANDAS symptoms.
Medical Treatments
Anti-inflammatory medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, may be used to reduce brain inflammation associated with the autoimmune response. For more severe cases, immunomodulatory therapies are considered. These include Intravenous Immunoglobulin (IVIG), which administers concentrated antibodies to help reset the immune system, and plasmapheresis, a procedure that removes harmful autoantibodies from the blood.
Symptomatic Treatments
Symptomatic treatments manage the neuropsychiatric aspects of the disorder. Cognitive behavioral therapy (CBT), particularly exposure and response prevention (ERP), can be beneficial for OCD-like behaviors and tics. Selective serotonin reuptake inhibitors (SSRIs) may be prescribed to address anxiety or mood disturbances. A multidisciplinary team, including pediatricians, neurologists, psychiatrists, and therapists, often collaborates to provide comprehensive care for children with PANDAS.