Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep infectionsWe have previously addressed the notion that “Not All That Shakes is a Seizure.” Often, just by witnessing the “shaking” it is possible to lower the concern for seizures; however, refrain from being dismissive, as there are a number of other conditions that may lead to unusual shaking, twitching, and tic-ing.  Chorea, for example, can be quite alarming to see.  Occasionally, someone may also mention a condition that causes me to stare blankly. One of these befuddling conditions is even associated with Strep Infection… perfect… kids love to collect strep!  Let’s take a moment to review PANDAS (no, not the large furry mammal that eats bamboo) so that we may appear less befuddled.


PANDAS: Background

  • PANDAS = Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
  • Relatively new condition that was first described in 1998. [Swedo, 1998]
  • Association with Strep Infections is still debated, but condition recognized a homogenous group of children. [Williams, 2014]
    • Some chose to view PANDAS as a subset of PANS (Pediatric Acute-onset Neuropsychiatric Syndrome).
    • Essentially, the understanding of the condition is still in its infancy.
  • Etiology:
    • Exact pathogenesis of PANDAS is not yet clarified.
    • Possibly related to molecular mimicry between GAS and CNS epitopes leading to post-infectious autoimmunity in susceptible kids. [Esposito, 2014]


PANDAS: Diagnostic Criteria

  • MUST HAVE[Swedo, 2015; Swedo, 1998]
    1. Presence of OCD and/or Tic Disorder
      • Obsessional fears of contamination or harm to self/others
      • Compulsions involving washing, checking, repeating, and counting
      • Tic disorder – involuntary motor tics (ex, nose twitching, eye blinking, head jerking, vocal tics, coughing, throat clearing)
      • Often also have neuropsychiatric symptoms:
        • Ex, anxiety, emotional lability, ADHD, Oppositional-defiant disorder, behavior regressions
        • Again, these develop acutely and may be what catches family’s attention.
    2. Prepubertal onset
      • Mean age = 6 years.
      • Also distinguishes it from typical OCD, which has later onset.
    3. Abrupt onset or Exacerbation of symptoms with an episodic course
      • Key feature is the acute and rapid onset of symptoms!
      • Typically, patient was healthy previously.
    4. Associated neurologic abnormalities
      • Choreiform movements
      • Urinary urgency/ frequency due to enuresis
      • Sleep disorders (ex, parasomnias)
    5. Temporal association between symptoms and Group A Strep infection
      • No defined time window, but typically within 6 weeks
      • Debated feature, as GAS infection is common in children
      • GAS leading to pharyngitis or skin infections (ex, perianal) have been implicated. [Toufexis, 2014]


PANDAS: Treatment

  • Primary treatment is symptomatic.  [Esposito, 2014]
    • Cognitive behavioral therapy
      • Methods and tools to recognize triggers for tics and means to counteract them.
      • Stress is a common exacerbating cause.
    • Family counseling
    • Psychoeducation
  • Antibiotics (Penicillin)
    • Mixed results about utility of antibiotic therapy.  [Esposito, 2014]
    • Some evidence that Penicillin is associated with improvement in tics.
    • If the condition is related to autoimmune disorder, antibiotics being effective seems odd.
  • Dopamine Antagonists
    • Haloperidol and risperidone – used in severe cases of OCD.
    • Tiapride (not available in the USA) – useful for motor tics.
  • SSRIs may also be used for severe OCD.
  • Immune-modulatory Therapy
    • Plasma Apheresis or IVIG have been used, but should be reserved for severe cases.
    • Plasma Apheresis may even be helpful after the acute presentation. [Latimer, 2015]



Swedo SE1, Seidlitz J, Kovacevic M, Latimer ME, Hommer R, Lougee L, Grant P. Clinical presentation of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections in research and community settings. J Child Adolesc Psychopharmacol. 2015 Feb;25(1):26-30. PMID: 25695941. [PubMed] [Read by QxMD]

Williams KA1, Swedo SE2. Post-infectious autoimmune disorders: Sydenham’s chorea, PANDAS and beyond. Brain Res. 2015 Aug 18;1617:144-54. PMID: 25301689. [PubMed] [Read by QxMD]

Latimer ME1, L’Etoile N, Seidlitz J, Swedo SE. Therapeutic plasma apheresis as a treatment for 35 severely ill children and adolescents with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. J Child Adolesc Psychopharmacol. 2015 Feb;25(1):70-5. PMID: 25658452. [PubMed] [Read by QxMD]

Toufexis M, Deoleo C, Elia J, Murphy TK. A link between perianal strep and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS). J Neuropsychiatry Clin Neurosci. 2014 Apr 1;26(2):164-8. PMID: 24763762. [PubMed] [Read by QxMD]

Stagi S1, Rigante D2, Lepri G3, Bertini F3, Matucci-Cerinic M3, Falcini F3. Evaluation of autoimmune phenomena in patients with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Autoimmun Rev. 2014 Dec;13(12):1236-40. PMID: 25151976. [PubMed] [Read by QxMD]

Esposito S1, Bianchini S, Baggi E, Fattizzo M, Rigante D. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: an overview. Eur J Clin Microbiol Infect Dis. 2014 Dec;33(12):2105-9. PMID: 24953744. [PubMed] [Read by QxMD]

Wolf DS1, Singer HS. Pediatric movement disorders: an update. Curr Opin Neurol. 2008 Aug;21(4):491-6. PMID: 18607212. [PubMed] [Read by QxMD]

Swedo SE1, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S, Lougee L, Dow S, Zamkoff J, Dubbert BK. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998 Feb;155(2):264-71. PMID: 9464208. [PubMed] [Read by QxMD]


Sean M. Fox
Sean M. Fox
Articles: 583