Pediatric autoimmune neuropsychiatric disorders associated with

streptococcal infections (PANDAS) facts

PANDAS is an acronym for "pediatric autoimmune neuropsychiatric disorders associated
with streptococcal infections."

It is a fairly recently described disorder (1990s).

An autoimmune response to a streptococcal infection causes PANDAS.

It is diagnosed if there is a history of abruptly developing a number of neuropsychiatric

symptoms associated with a strep infection.

Medication and cognitive behavioral therapy are the primary treatments for PANDAS.

What is PANDAS?
PANDAS is an acronym which refers to "pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections." It is diagnosed clinically after a patient develops a
number of behavioral and physical symptoms following a strep throat infection.

Is PANDAS common?
PANDAS is a rare condition. It is believed that approximately one in 2,000 children are affected,
though the diagnosis may be overlooked due to some of the common symptoms associated with
the disease. In fact, there are some researchers who recommend including PANDAS in a
category of other disorders which include similar neuropsychiatric symptoms called CANS
(childhood acute neuropsychiatric symptoms) or PANS (pediatric acute-onset neuropsychiatric
syndrome).

What is the history of PANDAS?

PANDAS was described in the late 1990s after investigators identified a subgroup of children who
developed a sudden onset of obsessive-compulsive disorder (OCD) symptoms, vocal and motor
tics, and other behavioral changes. They identified that there was a common association in these
children, and that was identified as a recent or active infection with a beta-
hemolytic Streptococcus, the bacteria that causes strep throat. Researchers also identified a
number of other infectious agents, known to cause significant auto-inflammatory reactions
associated with neuropsychiatric symptoms, including influenza, varicella, and even Borrelia
burgdorferi (Lyme disease), but the diagnosis of PANDAS is limited to streptococcal
infections. Continue Reading
Medically Reviewed by a Doctor on 2/19/2015
What causes PANDAS?
PANDAS is in part caused by an autoimmune response to a strep infection.Streptococcus is
known to be associated with a number of immune-related disorders, including rheumatic fever,
scarlet fever, and acute glomerulonephritis (a kidney disorder). The strep molecules are known to
hide from the host immune system by mimicking host cells. Ultimately, the immune system
recognizes the foreign cells, and the antibodies produced attack the bacterium, and unfortunately,
some of the host's own cells due to cross-reactivity. In some situations, these antibodies attack
brain cells, causing OCD, tics, and other symptoms frequently observed in PANDAS patients.
What are symptoms and signs of PANDAS?
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PANDAS symptoms are similar to those of obsessive-compulsive disorder (OCD), attention deficit
hyperactivity disorder (ADHD), and motor or verbal tics. Symptoms tend to appear suddenly, and
the recovery period is variable. Often the symptoms may worsen during streptococcal infections
and improve in between.

How is PANDAS diagnosed?

PANDAS is diagnosed clinically. That means that it depends more on history and physical
examination rather than other specific studies. The following summarizes the five criteria used to
diagnose PANDAS:

1. Presence of obsessive-compulsive disorder (OCD) and/or a tic disorder, ADHD symptoms,

or oppositional behaviors

2. Abrupt onset and or symptoms vary in intensity

3. Association with neurological abnormalities, including motorhyperactivity, or abnormal

movements, such as choreiform movements (involuntary jerky movements), other
combinations of neuropsychiatric symptoms, such as anxiety, emotional lability, bedwetting,
or other regressive behaviors (temper tantrums), personality changes and deterioration in
math skills and handwriting

4. Onset of symptoms from age 3 years to puberty

5. Association with group A beta-hemolytic streptococcal infection (the bacteria that causes
strep throat) either by culture or other evidence of infection, such as scarlet fever or by
laboratory test evidence

As mentioned above, there are five criteria used to diagnose the disorder and must include the
sudden onset of OCD, tics, ADHD, or a rapid worsening of existing symptoms. To make the
diagnosis, one also needs evidence of a recent or active strep infection either by throat culture or
by other laboratory confirmative study of that infection (for example, antistreptolysin O or
antideoxyribonuclease B antibodies). Along with the clinical diagnosis, it is important to be sure
that there is not some other reason for the symptoms, and additional testing might be performed
for that reason. In fact, distinguishing PANDAS from Tourette's syndrome (a common tic
disorder), OCD, or Sydenham chorea (a movement disorder associated with rheumatic fever also
caused by Streptococcus) is not always a simple task.
What is the treatment for PANDAS?
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PANDAS is treated primarily with cognitive behavioral therapy and medication, depending on the
breadth and severity of symptoms. Currently, the primary medical therapy is focused on
controlling the OCD symptoms, and therefore selective serotonin reuptake inhibitor (SSRI)
medications are frequently used (fluoxetine [Prozac] and others). The other more acute measure
in treating PANDAS is treating the strep infection associated with the symptoms. Antibiotics are
the treatment of choice to eradicate an active strep throat infection. Your doctor may prescribe
penicillin, amoxicillin(Amoxil), azithromycin (Zithromax), or another antibiotic. For severe and
refractory symptoms, the use of other treatments aimed at controlling the immune response have
been studied and found to be effective. These include the use of intravenous immunoglobulin,
steroids, and plasmapheresis (plasma exchange therapy in which blood is withdrawn from an
individual and the liquid portion is removed and replaced and the blood is transfused back into the
individual). For both treatments, the "offending" antibodies are removed. Steroids are less
effective, because, although symptoms decrease during the treatment, they return soon after
stopping. More studies are needed to be able to recommend immune-modulating therapies
without hesitation.

What is the prognosis of PANDAS?

Though some children completely recover from PANDAS, there are some who develop persistent
neuropsychiatric symptoms or develop worsening symptoms after each strep infection. It is not
currently possible to predict which children will be affected or how severely. The mainstay of
therapy is to decrease the OCD, tics, or other behaviors which might interfere with daily life and
school.
Can PANDAS be prevented?
For those children diagnosed with PANDAS, there is some evidence that prophylactic antibiotics
may play a role in preventing the development of strep infections and therefore the worsening of
symptoms. More studies need to be performed to be sure that the preventive treatment is truly
effective. Surgical removal of the tonsils and adenoids has not shown to be effective in preventing
PANDAS