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Paediatric Autoimmune
Neuropsychiatric Disorders
Associated with Streptococcus
(PANDAS) is a recently discovered
condition in which an infection
leads to obsessive behaviours. The
common bug, Streptococcus, is
associated mainly with tonsillitis
and sore throats. In some, the
infection triggers antibodies that,
while fighting the infection, also
have an impact on the brain.
Classically, there is a clear history
of sudden-onset obsessive
behaviour following a sore throat;
remission of obsessions generally
follows resolution of the infection.
In terms of our children with
autistic spectrum disorder (ASD), it
is a useful diagnosis to consider.
PANDAS can be diagnosed
clinically, and there is a clear and
reasonably accurate array of lab
tests to confirm it. Also, it usually
responds to antibiotics
(azithromycin, penicillin or a
cephalosporin), and there is some
evidence it may respond to milder
antimicrobials such as olive leaf
extract or sage.
The tests can be performed at
any GP surgery or hospital, and
include: ASOT (a strep antibody
test), Anti-DNAse B (another
antibody test), or a throat swab.
In its classical form, and that is
to say its diagnosis, it is
uncommon in ASD. A small
percentage of those with
obsessive-compulsive disorder
Medical understanding
A condition associated with the common sore-throat
bug Streptococcus can lead to obsessive behaviour.
Its worth taking into consideration in children with
autism and it can be treated, says Dr Daniel Goyal
What throats
can tell us
If there is a sudden onset of
obsessive behaviours and then a
fairly sudden resolution, you should
contact your paediatrician and raise
the possibility of PANDAS
If there is marked obsessive
behaviour, then one must consider
Streptococcus. Is the throat sore, or
red? Are the glands up?
There is a difference between
repetitive behaviour and obsessive
behaviour. Obsessive is more
complex, and when interrupted
usually causes more distress
Other infections are probably
able to cause obsessive issues
Generally, improving the immune
system should be helpful, but it can
lead to a flare-up of symptoms.
Insist someone looks at the throat/
tonsils. A blood test taken during
the flare-up is useful
Antibiotics may be needed to get
the immune response settled down.
While this is not ideal, remember
that herbal remedies are antibiotics
too. Support the gut, and monitor
the results. Contacts, such as other
family members, may need to be
screened and/or treated to stop any
re-infection
Some suggest Streptococcus
may also be present in other sites
such as the ear or bowel. If so, an
antibody test will be required to
identify it
There are other treatment
methods available, such as a
tonsillectomy, but these need
expert advice and patient
consideration.
Key issues
Environmental
physician Dr Daniel
Goyal is a member of
the clinical team at
Breakspear Hospital
in Hertfordshire, UK,
where he runs several
environmental
medicine clinics and
two autism clinics
(OCD) behaviour and ASD do fulfil
the criteria for diagnosis (probably
less than 10%). However, PANDAS
raises some useful questions for
ASD, and particularly for those with
obsessive behaviours.
First, the discovery of
Streptococcus as a cause for a
mental health condition has been
quite a milestone. A disease that
would previously have been
treated through psychology or
psychopharmacology, often quite
successfully, can now be treated
through antibiotics. The immune
system, it would seem, can have
marked effects on behaviour.
This finding is further reinforced
by a recent study on mice, in
The immune system, it would seem, can
have marked effects on behaviour
which the immune system was
exchanged in mice suffering OCD,
with resolution of the OCD.
The experiment was not done to
propose exchanging the immune
system as a treatment modality, but
to emphasise that immunomodulation
may well be a good route to explore
in, at least, OCD.
Immunotoxicity
The second question pertains to
the inability of some children to get
rid of infections or respond
adequately to them. In our patient
group this is usually down to
immunotoxicity, and this essentially
means the immune system is
inhibited by an environmental toxin
from performing adequately. This
usually leads to prolonged and
unusual responses to infections.
Therefore, it may be that some
children develop obsessive-type
behaviours or thoughts secondary
to infection, but the behaviour does
not fully resolve or suddenly improve.
The infection (Streptococcus, for
example) may not resolve as it
does in a healthier immune system,
and hence the sudden onset and
sudden remission may not occur
either. Instead, there may be a
slow-burn OCD-type issue that may
fluctuate with a fluctuating immune
system. Our added difficulty is that
often our children cannot
communicate the sore throat or,
indeed, cannot perceive it as a
sore throat.
The third issue raised here
pertains to the actual mechanism
of illness. PANDAS is classed as
an autoimmune condition. That is,
the immune system overreacts to
an infection, with some issue
causing cross-reactivity. It is
almost an exaggerated immune
response. If the immune system is
impaired, such as is present in a
sub-group of ASD children, then
the full extent of what is actually
there (such as Streptococcus) may
only be realized once the immune
system starts to recover.
Often, we witness children doing
well apart from the obsessive side,
or that when nutrition improves the
immune response obsessions start
to flare-up. This is the time to
screen them for Strep-induced
behaviour problems, or, indeed,
other infections such as Clostridia,
yeast or HHV-6.