Makindo Medical Notes

Related Subjects: |Encopresis in Children |Enuresis/Bedwetting in Children |Acute Glomerulonephritis in Children |Nephrotic Syndrome in Children |Acute Appendicitis in Children |Gastro-oesophageal reflux in Children |Intussusception in Children |Panayiotopoulos Syndrome in Children |Reflex anoxic attacks in Children |Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

🧠 Introduction

• PANDAS describes a group of acute-onset neuropsychiatric disorders in children triggered by an autoimmune response to Group A β-haemolytic streptococcal (GAS) infection.
• Proposed mechanism: antibodies generated against streptococcal antigens cross-react with basal ganglia neurons (molecular mimicry), leading to abrupt psychiatric and neurological symptoms.
• First described in the late 1990s, PANDAS remains controversial and is considered a subtype of Paediatric Acute-onset Neuropsychiatric Syndrome (PANS).

⚠️ Key Clinical Features

• Obsessive–Compulsive Disorder (OCD): Rapid, dramatic onset of intrusive thoughts, compulsions, rituals.
• Tics: Motor or vocal tics resembling Tourette’s syndrome; often emerge suddenly after infection.
• Other Neuropsychiatric Symptoms: Emotional lability, anxiety, separation anxiety, irritability, behavioural regression.
• Somatic symptoms: Sleep disturbances, enuresis, handwriting deterioration, and in some cases food restriction or anorexia-like symptoms.

🧪 Diagnosis

• Diagnosis is clinical, supported by history of a recent streptococcal infection.
• Proposed criteria:
  • Presence of OCD and/or tic disorder.
  • Prepubertal onset (usually 3–12 years).
  • Abrupt onset with episodic course.
  • Temporal association with streptococcal infection.
  • Neurological abnormalities (e.g., hyperactivity, choreiform movements).
• Investigations: ASO titres or anti-DNase B may suggest recent strep exposure, but not diagnostic.
• Exclusion of other causes (e.g., Sydenham’s chorea, Tourette’s, primary OCD).

💊 Management

• Eradication of Streptococcus:
  • First-line: Antibiotics (penicillin V, amoxicillin, or azithromycin if penicillin-allergic).
  • Long-term prophylaxis sometimes considered in recurrent cases (though evidence mixed).
• Neuropsychiatric Symptom Management:
  • CBT and SSRIs for OCD (standard of care, as in non-PANDAS OCD).
  • Risperidone or other atypical antipsychotics for disabling tics/behavioural symptoms (specialist-led).
• Immunomodulation (specialist use only):
  • IVIG or plasmapheresis may benefit severe, refractory cases, but evidence remains limited and controversial.
• Supportive care: Multidisciplinary approach – child psychiatry, paediatrics, psychology, education support.

📈 Prognosis

• Symptoms often improve with antibiotics and psychiatric support, but relapses are common with new infections.
• Some children progress to chronic OCD or tic disorders despite treatment.
• Early recognition is essential to reduce long-term psychological and functional impact.

📌 Key Exam Pearls

• PANDAS is a clinical diagnosis – no specific lab test confirms it.
• Always rule out Sydenham’s chorea in post-strep neuropsychiatric presentations (part of rheumatic fever spectrum).
• Antibiotics may improve psychiatric symptoms → unique compared to primary OCD/Tourette’s.
• Still controversial – some guidelines (esp. in UK) prefer term PANS for broader differential.

🔗 References

• Elia J. et al, Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, J Child Neurol.
• Oxford Handbook of Clinical Medicine, p.692 – Tic Disorders.
• Royal College of Psychiatrists: Guidance on PANS/PANDAS (2020).