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Adult

• Young adults living fairly isolated lives, dependent on care from relatives.
• The illness was a tangible presence.
• They perceived a lack of knowledge among healthcare staff on PANS in healthcare, and negative consequences linked to this. Their experience-based knowledge of their own illness is devalued in healthcare encounters.
• A feeling of being pushed around in healthcare, without anyone taking responsibility for the treatment
• Emphasized the need for increased knowledge among staff to identify PANS and be able to offer effective treatment.

Ilyas U, Umar Z, Lin D (August 26, 2022) Group A Beta-Hemolytic Streptococcus-Induced Tic-Like Movement Disorder in an Adult: A Case Report. Cureus 14(8): e28451. doi:10.7759/cureus.28451

PANDAS in an Adult?: A Case Report. Deshmukh RP, Mane AB, Singh S.Ind J Priv Psychiatry 2022; 16 (1):44-45. DOI: 10.5005/jp-journals-10067-0104

“We report a case in order to suggest that we should be alert while assessing OCD in young patients, as it might be secondary to streptococcal infection. This has therapeutic implications. Trials of immunomodulator therapy can be given as suggested in a few kinds of literature. Although still experimental, it may have potential for the future, especially in those not responding to conventional treatment… This report might suggest that PANDAS-like syndrome may occur in adults also. We should be cautious of this syndrome during treatment.”

Letter to the Edito. Antistreptolysin-O Titers: Implications for Adult PANDAS. ANDREW J. CHURCH, B.SC., and RUSSELL C. DALE, M.B.CH.B., M.R.C.P., London, U.K. Published Online:1 Feb 2002. https://doi.org/10.1176/appi.ajp.159.2.320

To the Editor: A diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is made when neuropsychiatric disease is precipitated by streptococcal infection (1). Antistreptolysin-O titers are an important tool for diagnosing recent streptococcal infection in patients with Sydenham’s chorea and PANDAS, since throat cultures are usually negative because of the latent onset of the neuropsychiatric disease. The upper limit for normal antistreptolysin-O titers is 200 IU/ml in children, but no normal upper limit exists for healthy adults. We propose that an antistreptolysin-O titer of 270 IU/ml is the significant upper limit for healthy adults. This finding will aid in the investigation and diagnosis of new cases of adult PANDAS.

A Krouse, H Li, JA Krenzer, WN Rose. Plasmapheresis, Rituximab, and Ceftriaxone Provided Lasting Improvement for a 27-Year-Old Adult Male with PANDAS. Dept of Pathology, University of Wisconsin Hospital. Article

• At 17 – developed sudden psychosis and confusion after GAS infection. Had elevated anti-streptolysin O (ASO) titers. Did not present with typical symptoms of PANDAS – OCD and/or tic-like symptoms were not observed. A tentative diagnosis of PANDAS was given. Treated with antipsychotics, antibiotics, tonsillectomy, and IVIG which resulted in remissions and relapses of his neuropsychiatric symptoms.
• At age 27 – received a trial of therapeutic plasma exchange (TPE), rituximab, and ceftriaxone. Eventually resulted in sustained benefit and minimal fluctuations of his clinical symptoms.

Sophia Attwells, HBS; Elaine Setiawan, PhD; Alan A. Wilson, PhD, Pablo M. Rusjan, PhD; Romina Mizrahi, MD, PhD, FRCP(C); Laura Miler, HBS; Cynthia Xu, MD; Margaret Anne Richter, MD, FRCP(C); Alan Kahn, MD, FRCP(C); Stephen J. Kish, PhD; Sylvain Houle, MD, PhD, FRCP(C); Lakshmi Ravindran, MD, FRCP(C); Jeffrey H. Meyer, MD, PhD, FRCP(C)
JAMA Psychiatry 2017

The regional distribution of elevated TSPO VT argues that the autoimmune/neuroinflammatory theories of OCD should extend beyond the basal ganglia to include the cortico-striato-thalamo-cortical circuit. Immunomodulatory therapies should be investigated in adult OCD, rather than solely childhood OCD, particularly in cases with prominent distress when preventing compulsions.

Mental Health News Article
Brain Behavior Research Foundation Article

Sankaranarayanan, Anoop & John, J. (2003). Paediatric autoimmune neuropsychiatric disorders (PANDAS): A case report. The National medical journal of India. 16. 22-3. Read report

In view of the early onset of obsessive symptoms with periodic sudden exacerbations interspersed with periods of partial remissions, and the past history of streptococcal throat infection, the possibility of PANDAS was considered (Table I). However, he did not exhibit any abnormal movement, although he seemed fidgety and restless (Swedo2 has described ‘squirminess’ in some patients). In addition, the ASO titre done at our hospital was negative. It is, however, well accepted that not all exacerbations are preceded by group A beta-haemolytic streptococci (GABHS) infections and a prospective follow up is required to establish this association.

Note: Neither tics nor abnormal movements are required for a PANS diagnosis.