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Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS)

Graziella Orefici, PhD, Francesco Cardona, MD, Carol J. Cox, PhD, and Madeleine W. Cunningham, PhD.
From the Book: Streptococcus pyogenes Basic Biology to Clinical Manifestations – University of Oklahoma Health Sciences Center-2016
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The inclusion of a chapter on pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (or PANDAS) is essential to provide a history of the disease and provide current information about its association with Streptococcus pyogenes (group A streptococci), tics, obsessive compulsive disorder (OCD) and its relationship to Sydenham chorea (SC), which is the neurologic manifestation of acute rheumatic fever.

N-Acetylcysteine in the Treatment of Excoriation Disorder – A Randomized Clinical Trial

Jon E. Grant, JD, MD, MPH; Samuel R. Chamberlain, MD, PhD; Sarah A. Redden, BA; Eric W. Leppink, BA; Brian L. Odlaug, PhD; Suck Won Kim, MD
JAMA Psychiatry-2016

This investigation suggests that N-acetylcysteine appears to be effective and well tolerated in the acute treatment of SPD. As effective treatments for skin picking emerge, it becomes increasingly important that physicians and other mental health care professionals screen for the disorder to provide timely treatment.

Group A Streptococcus intranasal infection promotes CNS infiltration by streptococcal-specific Th17 cells

Thamotharampillai Dileepan, Erica D. Smith, Daniel Knowland, Martin Hsu, Maryann Platt, Peter Bittner-Eddy, Brenda Cohen, Peter Southern, Elizabeth Latimer, Earl Harley Dritan Agalliu. and P. Patrick Cleary
Journal of Clinical Investigation-2015
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Our results establish what we believe to be evidence of a novel crosstalk between the CNS and cellular immunity to infections, which may contribute to understanding the pathogenesis of many other CNS autoimmune diseases. Flare-ups associated with several chronic autoimmune conditions may be produced by the expansion of Th17 cells and the activation of cytokines induced by relatively common bacterial or viral infections. Aberrant cytokine expression could then disrupt the BBB to permit preexisting circulating autoantibodies to enter the brain, engage neural targets, and trigger the sudden onset of clinical symptoms.

Waking Up to a Child With Abrupt Personality Changes

Michelle M. Papachrisanthou, DNP, CPNP-PC, Renée L. Davis, DNP, CPNP-PC
Journal of Nurse Practitioners-2015

PANDAS can occur during or after a streptococcal infection.
PANDAS presents with sudden onset of personality changes.
Workup may be necessary to rule out other organic or mental health diagnoses.
Recognition is key to enable positive patient outcomes.

Implications for Advanced Practice Nurses When Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS) Is Suspected: A Qualitative Study

Molly McClelland, PhD, RN, Mary-Margaret Crombez, MEd, Catherine Crombez, BSc, Catherine Wenz, MSN, RN, FNP-BC, Margaret Lisius, MSW, Amanda Mattia, BSN, RN, Suzana Marku, BSN, RN
JPED-2015
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Using paradigmatic analysis of transcribed interviews, three themes were identified: fear, frustration, and not being heard.

Diagnosis Deconstructed: A Recipe for Encephalopathy

Morchi, Ravi MD
Emergency Medicine News-2015

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus Immunology: A Pilot Study

Walls A, Cubangbang M, Wang H, Raiji M, Knight J, Steehler M, Latimer E, Harley EH Jr.
Otolaryngol Head Neck Surg.-2015

Patients diagnosed with PANDAS appear to maintain significantly different concentrations of cytokines when compared with patients afflicted by chronic group A beta hemolytic streptococcus infections and obstructive sleep apnea. As a result, one could potentially use the described characterization of immunologic markers as a basis for future mechanistic and epidemiological studies.

The Role of Tonsillectomy in the Treatment of Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS)

Daniel Demesh, MD; Jordan M. Virbalas, MD; John P. Bent, MD
JAMA Otolaryngol Head Neck Surg.-2015

Conclusions: Although current evidence is inconclusive, the data reported herein support previously described smaller case series and further strengthens the notion that tonsillectomy may benefit patients with PANDAS whose symptoms are not controlled with antibiotic therapy

Detection of anti-streptococcal, antienolase, and anti-neural antibodies in subjects with early-onset psychiatric disorders

Nicolini H, López Y, Genis-Mendoza AD, Manrique V, Lopez-Canovas L, Niubo E, Hernández L, Bobes MA, Riverón AM, López-Casamichana M, Flores J, Lanzagorta N, De la Fuente-Sandoval C, Santana D.
Actas Esp Psiquiatr-2015

The simultaneous detection of all three of these antibodies could provide valuable information for the etiologic diagnosis of individuals with early-onset obsessive-compulsive disorders associated with streptococcal infection and, consequently, for prescribing suitable therapy.

Multidisciplinary Clinic Dedicated to Treating Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome: Presenting Characteristics of the First 47 Consecutive Patients

Jennifer Frankovich, Margo Thienemann, Jennifer Pearlstein, Amber Crable, Kayla Brown, Kiki Chang
JCAP-2015

In our PANS clinic, 40% of patients had acute onset of symptoms. However, those with and without acute onset of symptoms had similar symptom presentation, rates of inflammatory conditions, somatic symptoms, and violent thoughts and behaviors. GAS infections were the most commonly identified infection at onset and at symptom flares. Because of the wide variety of medical and psychiatric symptoms, youth with PANS may require a multidisciplinary team for adequate care management.

Five Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome of Differing Etiologies

Jennifer Frankovich, Margo Thienemann, Sonal Rana, Kiki Chang
JCAP-2015

Youth with PANS may present in differing ways, with psychiatric and physical symptoms overlapping with inflammatory or infectious diseases, pain syndromes, and other psychiatric diagnoses. Patients’ psychiatric symptoms may respond to treatments targeting the underlying cause of physical illness. Faced with a pediatric patient demonstrating the abrupt onset or exacerbation of psychiatric and physical symptoms, clinicians should consider PANS in their differential diagnosis.

Clinical Presentation of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections in Research and Community Settings

Susan E. Swedo, Jakob Seidlitz, Miro Kovacevic, M. Elizabeth Latimer, Rebecca Hommer, Lorraine Lougee, Paul Grant
JCAP-2015

The diagnostic criteria for PANDAS can be used by clinicians to accurately identify patients with common clinical features and shared etiology of symptoms. Although difficulties in documenting an association between GAS infection and symptom onset/exacerbations may preclude a diagnosis of PANDAS in some children with acute-onset OCD, they do appear to meet criteria for pediatric acute-onset neuropsychiatric syndrome (PANS).