Pandas Syndrome: Symptoms, Types, Causes and Treatment

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is a complex and often misunderstood condition that primarily affects children. It is marked by the abrupt onset of obsessive-compulsive behaviors, tics, and other neuropsychiatric symptoms following a streptococcal infection. This article will guide you through the key symptoms, types, underlying causes, and the latest evidence-based treatments for PANDAS syndrome, based on current research.

Symptoms of Pandas Syndrome

When a child suddenly changes in behavior—becoming obsessive, anxious, or developing tics seemingly overnight—it can be frightening for families. PANDAS syndrome is characterized by just such an abrupt transformation, often following a streptococcal infection. Recognizing the hallmark symptoms is essential for early intervention and management.

Symptom	Description	Frequency/Severity	Source(s)
OCD Symptoms	Sudden onset of intrusive thoughts, compulsions	Very Common, Severe	1 3 5 8
Tics	Motor and vocal tics, abrupt in onset	Common, Moderate	1 3 5 8 12
Emotional Lability	Mood swings, irritability, anxiety	Common	2 5 8 4
Psychotic Symptoms	Hallucinations, delusions (in some cases)	Less Common, Severe	4 2

Table 1: Key Symptoms of PANDAS Syndrome

Abrupt Onset and Course

• Sudden Appearance: The most striking feature is the rapid (often overnight) development of symptoms, especially obsessive-compulsive disorder (OCD) behaviors and tics 1 3 5 8.
• Relapsing-Remitting Pattern: Symptoms tend to wax and wane, with periods of improvement and abrupt exacerbations often linked to new infections 5 8.
• Temporal Link to Infection: The onset or worsening of symptoms is closely associated with a recent streptococcal infection, such as strep throat 1 3 5 9.

Neuropsychiatric and Behavioral Symptoms

• Obsessive-Compulsive Symptoms: Children may suddenly display repetitive behaviors, intrusive thoughts, or rituals that interfere with daily life 1 3 12.
• Tics: Both motor (e.g., blinking, grimacing) and vocal (e.g., grunting, throat clearing) tics are common and can be severe 1 3 12.
• Emotional Changes: Emotional instability, including irritability, anxiety, and even rage episodes, are frequently observed 2 5 8.
• Eating Restrictions: Some children develop abrupt food aversions or restrictive eating patterns, sometimes due to fears of contamination or choking 2.
• Psychotic Episodes: Rarely, children can experience hallucinations or delusional thinking during acute phases 4.

Additional Neurological Findings

• Motor Abnormalities: Hyperactivity, choreiform (dance-like) movements, and abnormal motor activation may be present 1 5 8.
• Cognitive Effects: Attention, learning, and memory may be temporarily affected, especially during acute episodes 6.

Types of Pandas Syndrome

The landscape of PANDAS and related disorders has evolved as researchers and clinicians have recognized a spectrum of acute-onset neuropsychiatric conditions in children. Understanding the different types helps in accurate diagnosis and tailored treatment.

Type	Key Features	Infection Link	Source(s)
PANDAS	OCD/tics with abrupt onset, streptococcal trigger	Required (Strep)	5 3 9 12
PANS	Acute OCD/tics, other psychiatric symptoms, any trigger	Not required	5 2 9
CANS	Childhood acute neuropsychiatric syndrome	Broad, not specified	5

Table 2: Types of Acute-Onset Pediatric Neuropsychiatric Syndromes

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)

• Definition: Characterized by abrupt onset of OCD and/or tic disorders following a Group A beta-hemolytic streptococcal (GAS) infection 3 5 8 12.
• Diagnostic Criteria: Five main criteria, including episodic course, prepubertal onset, and association with GAS 5 8.
• Associated Symptoms: Neurological abnormalities such as choreiform movements and hyperactivity 5 8.
• Requirement: Evidence of recent strep infection is essential for diagnosis 3 5 12.

PANS (Pediatric Acute-Onset Neuropsychiatric Syndrome)

• Expansion of Concept: Due to cases that did not meet all PANDAS criteria, PANS was defined to include children with abrupt-onset OCD or food restriction and at least two additional neuropsychiatric symptoms 5 9.
• Trigger: No requirement for documented strep infection; triggers may include other infections, metabolic disturbances, or unknown factors 5 2 9.
• Clinical Differences: Higher rates of irritability, aggression, and food restriction compared to PANDAS 2.

CANS (Childhood Acute Neuropsychiatric Syndrome)

• Most Inclusive: Encompasses a broad range of acute neuropsychiatric syndromes in children, regardless of cause 5.
• Usefulness: Provides a diagnostic home for children who do not fit PANDAS or PANS criteria but present with similar symptoms 5.

Causes of Pandas Syndrome

Unraveling the cause of PANDAS has been the subject of intense research and debate. The interplay between infection, immunity, and the brain offers fascinating insights into how the body's own defense mechanisms can sometimes go awry.

Cause	Mechanism	Impact on Brain	Source(s)
Streptococcal Infection	Triggers immune response	Initiates cascade	1 3 5 6 8
Autoimmunity	Cross-reactive antibodies attack brain tissue	Basal ganglia dysfunction	1 6 7 8
Genetic Factors	Genetic predisposition to abnormal response	Enhanced risk	1
Microbiota	Altered gut flora influences immunity	Modulates severity	1

Table 3: Main Causes and Mechanisms of PANDAS

Streptococcal Infection as a Trigger

• Group A Streptococcus: PANDAS is initiated by an infection with Group A beta-hemolytic streptococcus (GAS), most commonly presenting as strep throat 1 3 5 8.
• Temporal Association: The onset or relapse of symptoms closely follows the infection 3 5 12.

Autoimmune Mechanisms

• Molecular Mimicry: The immune system, while targeting the strep bacteria, produces antibodies that mistakenly cross-react with structures in the brain—especially the basal ganglia 1 3 6 7 8.
• Antibody Targeting: Research has found autoantibodies in PANDAS patients that bind to CNS epitopes, particularly cholinergic interneurons in the striatum 1 6 7.
• Functional Impact: These antibodies disrupt normal neuronal signaling, leading to OCD behaviors, tics, and other neuropsychiatric symptoms 6 7.

Genetic Predisposition

• Susceptibility Genes: Variations in immune-related genes, such as MBL and TNF-α, have been associated with an increased risk of developing PANDAS following infection 1.
• Family Patterns: Family history of autoimmune or neuropsychiatric disorders may increase vulnerability 2.

The Gut-Brain Axis

• Microbiota Changes: Some studies suggest that children with PANDAS have alterations in gut microbiota, which may influence immune responses and symptom severity 1.
• Bidirectional Influence: The gut-brain connection is an emerging area of interest in understanding PANDAS and related syndromes 1.

Ongoing Controversy

• Not Universally Accepted: Some experts question the strength of the link between strep infections and neuropsychiatric symptoms, and the precise autoimmune mechanisms remain under investigation 9 12.
• Diagnostic Challenges: No single biomarker or test can conclusively diagnose PANDAS, complicating research into its causes 12.

Treatment of Pandas Syndrome

Managing PANDAS requires a comprehensive, multidisciplinary approach. Because the syndrome straddles the boundaries between infection, immunity, and mental health, treatment strategies target each of these domains for the best outcomes.

Treatment Type	Main Intervention	Primary Benefit	Source(s)
Antibiotics	Penicillin, azithromycin	Treat infection, prevent relapse	2 10 13
Psychotherapy	Cognitive-behavioral therapy (CBT)	Reduce OCD, improve coping	2 11
Immunomodulation	IVIG, plasma exchange, corticosteroids	Reduce autoimmune activity	6 10 13
Psychiatric Medications	SSRIs, antipsychotics	Manage severe symptoms	2 11

Table 4: Main Treatments for PANDAS

Antibiotic Therapy

• Acute Treatment: Antibiotics such as penicillin or azithromycin are prescribed to eliminate streptococcal infection and reduce the risk of neuropsychiatric symptom exacerbation 2 10 13.
• Prophylaxis: In children with frequent relapses, long-term antibiotic prophylaxis may be considered to prevent recurrent infections and symptom flares 13.
• Current Evidence: While antibiotics are widely used, rigorous research into their long-term efficacy is still limited 10 12.

Psychotherapy

• Cognitive-Behavioral Therapy (CBT): CBT is particularly effective in treating obsessive-compulsive symptoms and supporting both patients and families 2 11.
• Family Involvement: Psychotherapy reduces stress for both children and their parents, improving quality of life 2.
• Behavioral Interventions: Tailored behavioral strategies can help manage tics and emotional symptoms during both acute and chronic phases 11.

Immunomodulatory Treatments

• IVIG and Plasma Exchange: In severe or refractory cases, intravenous immunoglobulin (IVIG) or plasma exchange can be used to reduce autoantibody levels and improve symptoms 6 10.
• Steroids: Short courses of corticosteroids may help alleviate acute neuropsychiatric symptoms by dampening inflammation 10 13.
• Risks and Benefits: These treatments are generally reserved for severe cases due to potential side effects and the need for more robust research on their benefits 10 12.

Psychiatric Medications

• SSRIs: Selective serotonin reuptake inhibitors can help manage severe OCD symptoms, though children may be more sensitive and require lower starting doses 2 11.
• Antipsychotics: Occasionally used for aggressive, psychotic, or severe tic symptoms 2.
• Individualized Approach: Medication regimens should be tailored to the child’s specific symptom profile, with careful monitoring for side effects 11.

Additional and Supportive Measures

• Infection Monitoring: Vigilant monitoring for new infections and prompt treatment is crucial to reduce relapses 13.
• Immunizations: Standard vaccinations are recommended, and attention to vitamin D status may be beneficial 13.
• Surgery: Adenotonsillectomy (removal of tonsils and adenoids) has limited evidence and is not routinely recommended 13.
• Probiotics: No clear benefit demonstrated, but they may be considered as part of supportive care 13.

Conclusion

PANDAS syndrome is a complex pediatric condition that bridges the fields of infectious disease, immunology, and psychiatry. Early recognition and comprehensive treatment can significantly improve outcomes for affected children and their families. The current research landscape, while evolving, provides valuable guidance for clinicians and caregivers.

Key Takeaways:

• Abrupt onset of OCD and/or tics, often after a strep infection, is the hallmark of PANDAS 3 5 8 12.
• PANDAS is part of a broader spectrum, including PANS and CANS, which encompass similar symptoms from varied triggers 5 9.
• Autoimmune mechanisms, genetic factors, and possibly gut microbiota all contribute to the pathogenesis 1 3 6 7.
• Treatment includes antibiotics, psychotherapy, immunomodulatory therapies, and psychiatric medications, with a multidisciplinary approach being most effective 2 10 11 13.
• Ongoing research is needed to refine diagnostic criteria and optimize treatment strategies for this challenging syndrome 10 12.

By staying informed and working closely with healthcare providers, families can help children with PANDAS achieve the best possible outcomes.