The Mystery Disease Affecting Our Kids. PANDAS?

by Lauro Amezcua-Patino, MD, FAPA.

Most of us have had it. If you have kids, so probably have they. Strep is the common name for a bacterial infection that can cause the infamous “Strep-Throat” that we all know so well. Strep throat accounts for about 30% of sore throats in children, and 5% to 15% of sore throats in adults. Typically, with some rest and maybe some ani-biotics, strep goes away within a week or so. However, there can be after effects. One is particularly pernicious, and potentially devastating, is called, P.A.N.D.A.

Strep-induced Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is a controversial condition proposed in the 1990s by Dr. Susan Swedo and her colleagues at the National Institute of Mental Health. PANDAS suggests that certain streptococcal infections can trigger a sudden onset of neuropsychiatric symptoms in children, including obsessive-compulsive disorder (OCD), tic disorders, anxiety, and other behavioral changes.

PANDAS and Mental Health:

The theory behind PANDAS is that in susceptible individuals, the body's immune response to a streptococcal infection can cross-react with brain tissue, leading to inflammation and subsequent neuropsychiatric symptoms. However, the existence and validity of PANDAS as a distinct clinical entity have been a subject of debate within the medical community.

Critics argue that the evidence supporting PANDAS is limited and that the proposed link between streptococcal infections and neuropsychiatric symptoms is not well-established. Furthermore, some studies have failed to replicate the findings of the initial research on PANDAS.

Despite the controversy, some clinicians continue to diagnose and treat PANDAS in children who present with sudden-onset neuropsychiatric symptoms following a streptococcal infection. Treatment typically involves antibiotics to treat the underlying infection, as well as interventions such as cognitive-behavioral therapy and psychotropic medications to manage the neuropsychiatric symptoms.

It is important to note that while streptococcal infections can lead to various complications, including rheumatic fever and certain autoimmune disorders, the connection between strep infections and neuropsychiatric symptoms, as proposed by PANDAS, remains a topic of ongoing research and debate.

Symptoms of PANDA:

The hallmark features of PANDAS include the sudden onset of symptoms, a relapsing-remitting course, and an association with streptococcal infections, particularly group A streptococcus (GAS). Symptoms often include OCD-like behaviors, tics, anxiety, emotional instability, and sometimes other neuropsychiatric manifestations. These include:

Obsessive-compulsive behaviors (OCD): Sudden onset or worsening of obsessive-compulsive behaviors, such as repetitive thoughts, compulsive rituals, or compulsive behaviors.

Tics: Sudden onset or worsening of motor or vocal tics, which are repetitive, involuntary movements or sounds.

Anxiety: Increased anxiety, including separation anxiety or generalized anxiety.

Emotional Lability: Rapid and intense mood swings, including irritability, sadness, or anger.

Hyperactivity or Impulsivity: Restlessness, fidgeting, difficulty staying still, or impulsive behaviors.

Difficulty with Attention and Concentration: Problems with focus, attention, and executive function.

Sudden Deterioration in Academic Performance: Decline in school performance or difficulty with tasks that were previously manageable.

It is important to note that these symptoms typically have a sudden onset or a sudden worsening and are often accompanied by other signs of infection, such as fever or sore throat. It is crucial for individuals experiencing these symptoms to seek medical evaluation and treatment, as prompt intervention can help manage the condition effectively.

Diagnosing PANDAS:

Diagnosing PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) can be challenging, as there are no specific laboratory tests or imaging studies that definitively confirm the condition. However, clinicians typically consider a combination of clinical criteria and medical history to make a diagnosis. Here's how PANDAS is typically diagnosed:

Clinical Evaluation: The diagnosis of PANDAS begins with a thorough clinical evaluation by a healthcare provider, often a pediatrician or a child psychiatrist. The healthcare provider will review the child's medical history, including any recent or recurrent streptococcal infections, as well as the onset and progression of neuropsychiatric symptoms.

Symptom Assessment: PANDAS is characterized by the sudden onset of neuropsychiatric symptoms, typically following a streptococcal infection. Common symptoms include obsessive-compulsive behaviors (OCD), tic disorders, anxiety, emotional instability, and sometimes other neuropsychiatric manifestations. The healthcare provider will assess the child's symptoms and their impact on daily functioning.

Streptococcal Infection History: A key component of the diagnosis involves determining whether there is a temporal association between the onset of neuropsychiatric symptoms and a streptococcal infection. This may involve asking about recent episodes of strep throat or other streptococcal infections.

Laboratory Tests: While there are no specific laboratory tests for PANDAS, healthcare providers may perform certain tests to support the diagnosis or rule out other conditions. These may include throat swabs or blood tests to detect current or recent streptococcal infections, such as a rapid strep test or a streptococcal antibody titer.

Psychological Evaluation: A comprehensive psychological evaluation may be conducted to assess the child's neuropsychiatric symptoms, including standardized assessments of OCD symptoms, tic severity, anxiety, and other relevant domains.

Consultation with Specialists: In some cases, consultation with specialists such as pediatric neurologists, infectious disease specialists, or immunologists may be warranted to assist in the diagnosis and management of PANDAS.

It is important to note that the diagnosis of PANDAS remains controversial, and not all healthcare providers may recognize or accept it as a distinct clinical entity. Additionally, other conditions can present with similar neuropsychiatric symptoms, further complicating the diagnostic process. Therefore, a comprehensive evaluation by experienced clinicians is essential for accurate diagnosis and appropriate management.

?Treatment for PANDAS:

The treatment of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) typically involves a combination of addressing the underlying streptococcal infection, reducing inflammation, and managing neuropsychiatric symptoms. Here are some common approaches to treating PANDAS:

Antibiotics: If an active streptococcal infection is present or suspected, treatment with antibiotics is typically recommended to eradicate the infection and prevent further autoimmune reactions. Penicillin or other antibiotics effective against streptococcal bacteria may be prescribed. The duration and choice of antibiotic may vary depending on the severity of the infection and individual patient factors.

Anti-Inflammatory Medications: In cases where there is evidence of ongoing inflammation contributing to neuropsychiatric symptoms, anti-inflammatory medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids may be prescribed to help reduce inflammation and modulate the immune response.

Immunomodulatory Therapies: In some cases, immunomodulatory therapies may be considered to help regulate the immune system and reduce autoimmune responses. This may include treatments such as intravenous immunoglobulin (IVIG) therapy or plasmapheresis, although evidence supporting their efficacy in PANDAS is limited and the use of these therapies remains controversial.

Psychiatric Interventions: Neuropsychiatric symptoms associated with PANDAS, such as obsessive-compulsive behaviors (OCD), tic disorders, anxiety, and emotional instability, may require treatment with psychiatric interventions. This may include cognitive-behavioral therapy (CBT), which has been shown to be effective in treating OCD symptoms, as well as other forms of psychotherapy and behavioral interventions tailored to the individual needs of the child.

Psychotropic Medications: In cases where neuropsychiatric symptoms are severe or significantly impairing the child's functioning, psychotropic medications such as selective serotonin reuptake inhibitors (SSRIs), antipsychotics, or alpha-2 adrenergic agonists may be prescribed to help alleviate symptoms. These medications should be carefully selected and monitored by a healthcare provider with expertise in pediatric psychiatry.

Supportive Care: Providing supportive care and addressing any associated behavioral or educational challenges is an important aspect of managing PANDAS. This may include working with teachers and school personnel to accommodate the child's needs, providing social support, and addressing any comorbid conditions that may be present.

The optimal treatment approach for PANDAS may vary depending on individual factors such as the severity of symptoms, the presence of comorbid conditions, and the response to initial treatments. Treatment decisions should be made in collaboration with a multidisciplinary team of healthcare providers, including pediatricians, child psychiatrists, neurologists, and infectious disease specialists, with expertise in managing PANDAS. Additionally, ongoing research is needed to further elucidate the underlying mechanisms of PANDAS and to identify the most effective treatment strategies.

?Controversies:

Addressing the controversies surrounding Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) involves navigating a complex interplay of clinical, immunological, and psychiatric domains. At the core of the debate is the challenge of diagnosing a condition predicated on a set of criteria that includes sudden onset of obsessive-compulsive disorder (OCD) or tic disorders following a streptococcal infection, which critics argue can be subjective and potentially overlap with the natural progression of similar psychiatric conditions without an autoimmune trigger.

The hypothesis positing a causal link between streptococcal infections and subsequent neuropsychiatric symptoms is contentious, with detractors pointing to a lack of robust evidence establishing causality, exacerbated by methodological limitations such as small sample sizes and the difficulty of controlling confounding factors in observational studies.

Treatment protocols for PANDAS, including the use of antibiotics, immunotherapy, or tonsillectomy, further fuel the controversy, with proponents advocating for direct intervention to address the infection and critics cautioning against potential overuse of antibiotics and the absence of definitive, large-scale clinical trials to validate the efficacy of these treatments specifically for PANDAS. This debate extends beyond the confines of PANDAS to broader discussions in pediatric psychiatry regarding the interplay between the immune system and psychiatric symptoms, catalyzing interest in related conditions like Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and underscoring the need for interdisciplinary research.

?Despite these controversies, there is emerging consensus on the importance of collaborative research and clinical practice to elucidate the complexities of PANDAS and similar conditions, with future directions pointing towards rigorous trials, longitudinal studies, and investigations into the pathophysiological mechanisms underpinning these disorders.

The discourse surrounding PANDAS thus reflects broader themes in the evolution of psychiatric care, emphasizing a cautious, evidence-based approach while also heralding new avenues for understanding and treating psychiatric disorders in pediatric populations.

?Final Thoughts:

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) remains a complex and controversial condition that presents significant challenges in both diagnosis and treatment. While the concept of PANDAS proposes a link between streptococcal infections and neuropsychiatric symptoms in children, the existence and validity of this association continue to be debated within the medical community.

However, one cannot deny that some kids seem to have such dramatic shifts into psychological and even psychiatric issues after having strep.

Factors contributing to the variability in prevalence estimates include differences in study populations, diagnostic criteria, and methodologies used to identify cases. Moreover, P.A.N.D.A.S. is still not universally recognized by all healthcare professionals, which may complicate efforts to accurately determine its prevalence.

While P.A.N.D.A.S. is considered relatively rare, healthcare professionals need to be aware of the condition and its symptoms to facilitate early diagnosis and appropriate management for affected individuals.

I for one, will continue to scour the journals for additional data to help me better do my job.