PANDAS in LeRoy tic cases
PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. According to the National Institute for Mental Health, there are five diagnostic criteria that must be met for this to be a valid diagnosis.
- Presence of Obsessive-compulsive disorder and/or a tic disorder
- Pediatric onset of symptoms (age 3 years to puberty)
- Episodic course of symptom severity
- Association with group A Beta-hemolytic streptococcal infection (a positive throat culture for strep. or history of Scarlet Fever.)
- Association with neurological abnormalities (motoric hyperactivity, or adventitious movements, such as choreiform movements)
By definition, PANDAS is a pediatric disorder. It is possible that adolescents and adults may have immune mediated OCD, but this is not known. The research studies at the NIMH are restricted to children.
Case discussion from the American Journal of Psychiatry Am J Psychiatry 1998;155:1592-1598
PANDAS is not a diagnostic label, but an acronym designating a subgroup of children with OCD and tic disorders whose symptoms appear to be triggered by streptococcal infections.
The fourth criterion, temporal association between GABHS infections and symptom exacerbations, is the most important one for determining whether or not a child should be included in the PANDAS subgroup. The relationship between symptom exacerbations and GABHS infections must be established by demonstrating that the symptoms worsen in association with streptococcal pharyngitis and remit when the child is free of GABHS.
From Pediatrics Vol. 113 No. 4 April 1, 2004 pp. 883 -886
Therapy
What treatment should be considered for patients who present with the manifestations associated with the PANDAS constellation of symptoms?Neuropsychiatric Drugs
Children with disabling tics or OCD should receive appropriate treatment for their symptoms, including medications (eg, tic suppressants such as ?-agonists, classical or atypical antipsychotics, or antiobsessional drugs such as selective serotonin-reuptake inhibitors) or nonpharmacologic approaches (eg, cognitive behavioral therapy for OCD).24Antibiotics to Prevent Strep Infections
The only published clinical trial of prophylactic penicillin in children with this syndrome revealed no conclusive evidence that the antibiotic reduced clinical exacerbations.25 Admittedly, the duration of that study was too short to allow definite conclusions. A later report suggesting improvement of new-onset or acute exacerbations of symptoms in such children with antibiotics provides inadequate support for such an approach, because treatment was not placebo-controlled and was unblinded.26 It is well known in treatment studies of TS that there is a substantial placebo effect; the natural course of TS and OCD is such that exacerbations are followed by remissions. This latter phenomenon of “reversion to the mean” implies that virtually any intervention at the time of peak symptoms may seem successful. Only a double-blind, placebo-controlled study can identify a true therapeutic effect.Another reason to feel comfortable with avoiding antibiotic treatment for these patients is that, to date, no cases have been reported to develop any rheumatic carditis as occurs in patients with Sydenham’s chorea. This is a very important point to remember, because some have attempted to relate this syndrome to rheumatic fever. It is recognized that as many as one third of patients with Sydenham’s chorea ultimately will have evidence of rheumatic valvular heart disease.27 This issue requires additional investigation, because the lack of heart disease strongly argues against a relationship between PANDAS and Sydenham’s chorea or other forms of rheumatic fever.
PANDAS references:
National Institute of Mental Health
NYS Department of Health report released February 3, 2012
Peter D. Springberg, M.D., FACP
International OCD Foundation PANDAS Fact Sheet
What every psychiatrist should know about PANDAS: a review Clinical Practice and Epidemiology in Mental Health 2008, 4:13
PANDAS – PITAND Awareness & Research Support
International PANDAS Foundation
PANDAS Resource Network
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There are strong reasons to be comfortable with antibiotic use for infectious triggers of PANDAS-PITAND when a physician prescribes them. Perhaps the best reason to utilize antibiotics for PANDAS-PITAND conditions is because following an infectious trigger (such as Streptococcus Pyogenes, Mycoplasma Pneumoniae, tick-borne infections, including Lyme disease, Ehrlichiosis, Babesia and Bartonella) in this autoimmune disease, the blood brain barrier is breached and through the process of molecular mimicry, antibodies attack the basal ganglia area of the brain, causing inflammation, which alters function. We’re all aware why it’s important to protect brain function – it’s a vital organ.
The references that you cited are out of date and incomplete. There are several more recent scientific publications, which I’d encourage you to read. Here are a few:
Neurocognitive functioning in youth with pediatric autoimmune neuropsychiatric disorders associated with streptococcus. Lewin AB, et al. (September, 2011)
Clinical Factors Associated with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Murphy, TK, et al (2011)
The Immunobiology of Tourette’s Disorder, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus and Related Infections: A Way Forward. Murphy, et al (2010)
Maternal history of autoimmune disease in children presenting with tics and/or obsessive–compulsive disorder. Murphy, et al (2010)
Passive transfer of streptococcus-induced antibodies reproduces behavioral disturbances in a mouse model of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection. Yaddanapudi, K et al (2009)
Are antibasal ganglia antibodies important, and clinically useful? Martino, et al (2007)
Streptococcal Mimicry and Antibody-Mediated Cell Signaling in the Pathogenesis of Sydenham’s Chorea, Kirvan, et al (2006)
There is an IVIG study for PANDAS children currently underway at the NIMH (as well as other related studies). For information regarding the NIMH study – currently recruiting as of this date: http://clinicaltrials.gov/ct2/show/NCT01281969?term=ivig+pandas&rank=1 In the meantime, I’d encourage you to review this one:
Therapeutic Plasma Exchange and Intravenous Immunoglobulin for Obsessive-Compulsive Disorder and Tic Disorders in Childhood. Perlmutter, et al (1999)
Denise Greaud Grubbs, RN
PANDAS-PITAND Awareness & Research Support, Director