Childhood Acute Neuropsychiatric Symptoms

Aka: Childhood Acute Neuropsychiatric Symptoms, PANDAS, Pediatric Autoimmune Neuropsychiatric Disorders, Post-streptococcal Autoimmune Neuropsychiatric Disorder, Streptococcal Associated Neuropsychiatric Disorder

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II. Definition

  1. Pediatric Autoimmune Neuropsychiatric Disorders
  2. Associated with Streptococcal Infections

III. Precautions

  1. Controversial diagnosis
    1. Streptococcal infection is common (PANDAS follows infection by 4-6 weeks)
    2. Tic Disorders are common
    3. When both are present, is it simply coincidence?
  2. Avoid testing ASO Titers (rarely helpful)
  3. Even if diagnosis is made, there is no treatment
    1. Even daily Penicillin does not alter Tic Disorder

IV. Pathophysiology

  1. Multiple infectious, toxic and metabolic causes have been proposed
    1. Initially thought specific to autoantibody formation in response to streptococcal infection
      1. Associated with Group A Beta Hemolytic Streptococcus
  2. Autoantibodies stimulate basal ganglia Autoimmune Disease
  3. Similar mechanism as Rheumatic Fever and PSGN

V. Differential Diagnosis

  1. Rheumatic Fever
    1. Jones Criteria include Sydenham Chorea in addition to carditis, Polyarthritis, Erythema Marginatum, skin Nodules

VI. Associated conditions

  1. See Obsessive-Compulsive Disorder
  2. See Tic Disorder
  3. Sydenham's Chorea
  4. Rheumatic Fever

VII. Diagnosis: Criteria (all 5 criteria need to be present)

  1. Psychiatric illness
    1. Obsessive-Compulsive Disorder
    2. Tic Disorder
  2. Prepubertal symptom onset
  3. Acute, severe onset with symptom exacerbations
  4. Neurologic abnormalities
    1. Example: Choreiform movements
  5. Exacerbation follows Group A streptococcal infection
    1. History of streptococcal infection OR
    2. Positive Antistreptolysin O (ASO Titer) OR
    3. Antideoxyribonuclease B Antibody (xADB)

VIII. Management

  1. Cognitive Behavioral Therapy
  2. Selective Serotonin Reuptake Inhibitors
  3. Other agents directed at autoimmune response have been used
    1. Corticosteroids
    2. IV Immunoglobulin
    3. Plasmaphoresis

IX. References

  1. Farhood (2016) Int J Pediatr Otolaryngol 89:149-53 [PubMed]
  2. Maness (2018) Am Fam Physician 97(8): 517-22 [PubMed]
  3. Singer (2012) J Pediatr 160(5): 725-31 [PubMed]

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