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child:pandas [on March 19, 2020]
child:pandas [on March 9, 2021] (current)
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 ====== Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) ====== ====== Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) ======
 +{{INLINETOC}}
 +===== Primer =====
 +**Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS)** is the presence of [[ocd:​1-ocd|]] and/or [[child:​motor:​tic-disorders|tic disorder]] at prepubertal age of onset with abrupt onset and relapsing-remitting symptom course. The defining features are a temporal association between symptom exacerbations and a Group-A beta-hemolytic streptococcal (GAS) infection. There are also neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity). PANDAS remains a somewhat controversial diagnosis.[([[https://​pubmed.ncbi.nlm.nih.gov/​30996598/​|Wilbur,​ C., Bitnun, A., Kronenberg, S., Laxer, R. M., Levy, D. M., Logan, W. J., ... & Yeh, E. A. (2019). PANDAS/PANS in childhood: Controversies and evidence. Paediatrics & child health, 24(2), 85-91.]])]
 +
 +== Prognosis ==
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​
 +See also: **[[https://​pubmed.ncbi.nlm.nih.gov/​29119300/​|Leon,​ J., Hommer, R., Grant, P., Farmer, C., D’Souza, P., Kessler, R., ... & Swedo, S. (2018). Longitudinal outcomes of children with pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS). European child & adolescent psychiatry, 27(5), 637-643.]]**
 +</​alert>​
 +
 +===== Diagnostic Criteria =====
 +==== NIMH Criteria ====
 +The NIMH Criteria (2004) propose the following:​[([[https://​pubmed.ncbi.nlm.nih.gov/​15241433/​|Snider,​ L. A., & Swedo, S. E. (2004). PANDAS: current status and directions for research. Molecular psychiatry, 9(10), 900-907.]])]
 +  - OCD or tic disorder
 +  - Onset: age 3 to puberty
 +  - Abrupt onset or exacerbating course
 +  - Strep infection leading to onset/​exacerbation of symptoms
 +  - Neurological abnormalities
 +
 +==== Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) ====
 +**Pediatric acute-onset neuropsychiatric syndrome (PANS)** is a condition defined by sudden onset of obsessive-compulsive symptoms and/or severe eating restrictions,​ along with at least two other cognitive, behavioural,​ or neurological symptoms. This diagnostic construct allows for identification of cases without clear evidence of autoimmune process, and is not restricted to streptococcal infection:​[([[https://​pubmed.ncbi.nlm.nih.gov/​28722464/​|Swedo,​ S. E., Frankovich, J., & Murphy, T. K. (2017). Overview of treatment of pediatric acute-onset neuropsychiatric syndrome. Journal of child and adolescent psychopharmacology,​ 27(7), 562-565.]])]
 +
 +  - Abrupt, dramatic onset of OCD or anorexia
 +  - Concurrent presence of ''​2''​ or more additional neuropsychiatric symptoms with similarly severe and acute onset. These include:
 +    * Anxiety
 +    * Mood swings and depression
 +    * Aggression
 +    * Irritability and oppositional behaviors
 +    * Developmental regression
 +    * Sudden deterioration in school performance or learning abilities
 +    * Sensory and motor abnormalities
 +    * Somatic signs and symptoms
 +  - Symptoms are unexplainable by a known neurologic or medical disorder
 +
 +===== Treatment =====
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​
 +See also: **[[https://​pubmed.ncbi.nlm.nih.gov/​29309797/​|Sigra,​ S., Hesselmark, E., & Bejerot, S. (2018). Treatment of PANDAS and PANS: a systematic review. Neuroscience & Biobehavioral Reviews, 86, 51-65.]]**
 +</​alert>​
 +Unfortunately,​ detailed and consensus recommendations for the treatment of PANDAS remain lacking, and various treatments have been used (but have high risk for bias).[([[https://​pubmed.ncbi.nlm.nih.gov/​29309797/​|Sigra,​ S., Hesselmark, E., & Bejerot, S. (2018). Treatment of PANDAS and PANS: a systematic review. Neuroscience & Biobehavioral Reviews, 86, 51-65.]])] Some general treatment principles include:
 +  * Any acute streptococcal infection should be treated with antibiotics.
 +  * However, elevated strep titers only indicate that a patient has //had// strep exposure; it is unable to indicate //when// the strep infection occurred. Thus, children may have continue to have "​positive"​ titers for many months after a single infection.
 +  * Prophylactic antibiotic use post-acute infection has been shown to be useful in one study, but this randomized control trial lacked a non-placebo control group.[([[https://​pubmed.ncbi.nlm.nih.gov/​15820236/​|Snider,​ L. A., Lougee, L., Slattery, M., Grant, P., & Swedo, S. E. (2005). Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders. Biological psychiatry, 57(7), 788-792.]])]
 +  * Patients can benefit from cognitive behavioural therapy (CBT) at any point as it is a minimally invasive treatment approach.[([[https://​pubmed.ncbi.nlm.nih.gov/​17003662/​|Storch,​ E. A., Murphy, T. K., Geffken, G. R., Mann, G., Adkins, J., Merlo, L. J., ... & Goodman, W. K. (2006). Cognitive-behavioral therapy for PANDAS-related obsessive-compulsive disorder: findings from a preliminary waitlist controlled open trial. Journal of the American Academy of Child & Adolescent Psychiatry, 45(10), 1171-1178.]])]
 +  * Selective serotonin reuptake inhibitors (SSRIs) may be indicated in more severe cases.
 +===== Resources =====
 +== For Patients ==
 +  * [[https://​www.nimh.nih.gov/​health/​publications/​pandas/​index.shtml|NIMH:​ PANDAS—Questions and Answers]]
 +
 +== Research ==
   * [[http://​jamanetwork.com/​journals/​jamapsychiatry/​fullarticle/​2629065|Orlovska,​ S., Vestergaard,​ C. H., Bech, B. H., Nordentoft, M., Vestergaard,​ M., & Benros, M. E. (2017). Association of Streptococcal Throat Infection With Mental Disorders: Testing Key Aspects of the PANDAS Hypothesis in a Nationwide Study. JAMA psychiatry.]]   * [[http://​jamanetwork.com/​journals/​jamapsychiatry/​fullarticle/​2629065|Orlovska,​ S., Vestergaard,​ C. H., Bech, B. H., Nordentoft, M., Vestergaard,​ M., & Benros, M. E. (2017). Association of Streptococcal Throat Infection With Mental Disorders: Testing Key Aspects of the PANDAS Hypothesis in a Nationwide Study. JAMA psychiatry.]]
   * [[https://​www.ncbi.nlm.nih.gov/​pubmed/​30996598|Wilbur,​ C., Bitnun, A., Kronenberg, S., Laxer, R. M., Levy, D. M., Logan, W. J., ... & Yeh, E. A. (2019). PANDAS/PANS in childhood: Controversies and evidence. Paediatrics & child health, 24(2), 85-91.]]   * [[https://​www.ncbi.nlm.nih.gov/​pubmed/​30996598|Wilbur,​ C., Bitnun, A., Kronenberg, S., Laxer, R. M., Levy, D. M., Logan, W. J., ... & Yeh, E. A. (2019). PANDAS/PANS in childhood: Controversies and evidence. Paediatrics & child health, 24(2), 85-91.]]