Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a rare disorder characterized by the presence of obsessive-compulsive disorder or tic disorder, acute onset and episodic course, pediatric onset, presence of associated neurological abnormalities, and temporal association with group A streptococcal infection.
Presentation
The clinical course of PANDAS is characterized by an episodic pattern of symptoms with acute onset of OCD symptoms and significant comorbidity associated with the exacerbations. Emotional lability, school issues, anxiety, nighttime fears and bedtime rituals, urinary symptoms, cognitive deficits, depression, behavioral regression, deterioration in math skills and handwriting and motoric hyperactivity are frequently observed [7] [8] [9] [10].
Entire Body System
- Streptococcal Infection
Due to the high incidence of group A streptococcal infections in the pediatric population and GAS carriage, the exact relationship between PANDAS and group A streptococcal infection is difficult to establish. [symptoma.com]
Recently a tic disorder occurring after group A streptococcal infection has been described and termed PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection). [ncbi.nlm.nih.gov]
- Falling
Pandas earn Canada West Bronze with win over UBC Pandas beat UBC in penalty kicks, earn first conference medal since 2013 Pandas soccer knocked out in semifinal Pandas comeback falls just short, fall 3-2 to Trinity Western in CW semifinal Trio of Pandas [ualberta.ca]
The collars are designed to fall off after 2 years. How big was the territory of the pandas you studied? On average, the pandas were moving in an area about 4.38 square Km – or about 2 square miles. [dailymail.co.uk]
In fall 2014, Ms. Maloney’s office drafted a letter, directed at Chinese officials, for the mayor to sign. [nytimes.com]
They do search for mates in the spring, and females will give birth to a cub or two in the fall. Unfortunately, the giant panda 's birth rate is quite low. [wonderopolis.org]
[…] moments and dopey-funny music cues (pandas slithering up branches and falling down slides to the tune of ZZ Top’s “Sharp Dressed Man”), along with a spun-sugar narration by Kristen Bell (“He’s the King Kong of cute!”). [variety.com]
- Episodic Course
The clinical course of PANDAS is characterized by an episodic pattern of symptoms with acute onset of OCD symptoms and significant comorbidity associated with the exacerbations. [symptoma.com]
It describes the presence of obsessive-compulsive disorder (OCD) or tics with an episodic course, and a temporal relationship to Group A beta haemolytic streptococcal infection (GABHS). [ncbi.nlm.nih.gov]
- Streptococcal Pharyngitis
pharyngitis Our Mission PANDAS Network is dedicated to improving the diagnosis and treatment of children with PANDAS. [pandasnetwork.org]
"Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease [en.m.wikipedia.org]
- Disability
This is disabled by default. In addition, optimizations enabled by ‘spark.sql.execution.arrow.enabled’ could fallback automatically to non-Arrow optimization implementation if an error occurs before the actual computation within Spark. [spark.apache.org]
[…] diagnosis requires two of the following symptoms, according to the National Institute of Mental Health : anxiety, emotional instability/depression, oppositional behavior like aggression, losing development in behavior, worsening of school performance, disabilities [abcnews.go.com]
But Agalliu says a "wait and see" approach is unethical when it comes to diagnosing PANDAS, since prompt treatment saves lives and prevents long-term disability. [aol.com]
Psychiatrical
- Compulsive Disorder
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are a well-defined cause of obsessive-compulsive disorder in children. [ncbi.nlm.nih.gov]
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a rare disorder characterized by the presence of obsessive-compulsive disorder or tic disorder, acute onset and episodic course, pediatric onset, presence [symptoma.com]
- Fear
Restrictions in food intake are typically fueled by contamination fears; fears of choking, vomiting, or swallowing; and/or sensory issues, such as texture, taste, or olfactory concerns. However, body image distortions may also be present. [ncbi.nlm.nih.gov]
Symptoms may include tics, obsessions, compulsions, anxiety, emotional lability, night-time fears, mood changes, hyperactivity, sleep disturbance, deterioration in math skills and handwriting and cognitive deficits. [symptoma.com]
Children develop habits and fears quickly and they may use ERP treatment to teach their brain to ignore the irrational fear signals they have been receiving. ERP teaches a child concrete tools to overcome OCD thoughts on a daily basis. [iocdf.org]
[…] pneumonia can suddenly bring on a complicated disorder with symptoms such as: Sudden Personality Changes Obsessions / Compulsions Motor and/or Vocal Tics / Choreiform Movements Generalized Anxiety / Emotional Lability Oppositional Defiance / Rages Bedtime Fears [pas.care]
Children will most frequently have an acute and sudden onset of obsessions and compulsions (for example excessive contamination fears and handwashing, over focus on need for things to feel or be "right" resulting in ordering or checking behaviours) and [anxietycanada.com]
- Compulsive Behavior
As defined, the criteria include prepubertal children with either a tic or obsessive-compulsive disorder in whom a Group A beta-hemolytic streptococcal infection (GABHS) triggers the abrupt onset or exacerbation of tics/obsessive-compulsive behaviors. [ncbi.nlm.nih.gov]
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) is the sudden, rapid-onset of obsessive compulsive behavior, as well as possible movement and behavioral abnormalities, following a Streptococcus pyogenes (Group A Strep [kids.iocdf.org]
PANDAS is characterized by an abrupt onset of obsessive-compulsive behaviors (OCD) and/or motor or vocal tics in pre-pubescent children immediately following a group A Strep (GAS) infection. [moleculeralabs.com]
They include behaviors similar to obsessive-compulsive disorder (OCD) and Tourette syndrome. These symptoms can interfere with schooling and quickly become debilitating. [healthline.com]
- Obsessive Thoughts
Watch for changes in the child's behaviours that are unexplained or out of character, such as mood changes, clinginess, hyperactivity, inattentiveness, obsessive thoughts, checking behaviours, repetitive noises or vocalisations, poor muscle control or [adhd.com.au]
The obsessive thoughts, compulsive behaviors, and motor or vocal tics appeared “overnight and out of the blue” and usually reached full-scale intensity within 24-48 hours. [nimh.nih.gov]
- Auditory Hallucination
Psychological symptoms may include: obsessive, compulsive, and repetitive behaviors separation anxiety, fear, and panic attacks incessant screaming, irritability, and frequent mood changes emotional and developmental regression visual or auditory hallucinations [healthline.com]
Sensory abnormalities, including hyper-sensitivity to light or sounds, distortions of visual perceptions, and occasionally, visual or auditory hallucinations e. [nimh.nih.gov]
Neurologic
- Hyperactivity
Symptoms may include tics, obsessions, compulsions, anxiety, emotional lability, night-time fears, mood changes, hyperactivity, sleep disturbance, deterioration in math skills and handwriting and cognitive deficits. [symptoma.com]
He also exhibited neuro-psychiatric symptoms including agitation, hyperactivity, and tics. These symptoms followed his recurrent infections. [ncbi.nlm.nih.gov]
- Confusion
Selection Options There’s three main options to achieve the selection and indexing activities in Pandas, which can be confusing. [shanelynn.ie]
Again, this is confusing because it can accept integers or labels. [medium.com]
Barry Schwartz | Jan 21, 2016 at 9:23 am ET SEOs Confused, Puzzled After Google’s Mystery Update Below is a summary of some of the questions, answers and additional confusion around the Google core algorithm update this weekend and the Panda... [searchengineland.com]
If you're lost, confused, or need some clarity, don't hesitate to ask questions on the respective videos. The next tutorial: [pythonprogramming.net]
- Personality Change
Thank you for your support Illnesses including strep throat, mononucleosis, and pneumonia can suddenly bring on a complicated disorder with symptoms such as: Sudden Personality Changes Obsessions / Compulsions Motor and/or Vocal Tics / Choreiform Movements [pas.care]
Medical professionals who are not familiar with this condition may attribute the personality changes to rebellious developmental stages, or poor parenting. [moleculeralabs.com]
Rebecca’s Video Rebecca was an outgoing child whose personality changed dramatically after a strep infection. Receiving a PANDAS diagnosis gave her family hope. Hear her story of diagnosis, treatment and recovery from PANDAS. [pandasnetwork.org]
[…] motor hyperactivity, or abnormal movements, such as choreiform movements (involuntary jerky movements), other combinations of neuropsychiatric symptoms, such as anxiety, emotional lability, bedwetting, or other regressive behaviors ( temper tantrums ), personality [medicinenet.com]
- Tantrums
Developmental regression, including temper tantrums, "baby talk" and handwriting deterioration (also related to motor symptoms) 5) Association with streptococcal infection. [nimh.nih.gov]
[…] including motor hyperactivity, or abnormal movements, such as choreiform movements (involuntary jerky movements), other combinations of neuropsychiatric symptoms, such as anxiety, emotional lability, bedwetting, or other regressive behaviors ( temper tantrums [medicinenet.com]
As an example, a normally joyful, balanced emotionally, independent, social child may turn into a child that has extreme temper tantrums that are out of character, and can no longer leave a parent’s side without accommodation. [iocdf.org]
- Screaming
And yesterday, she screamed about her clothes suddenly being too tight. She is petrified when I leave her, and she follows me around the house yelling at me to help her. But everything I do is wrong. [anxietycanada.com]
Imagine a child screaming in terror in a corner, and a parent unable to hold them. These parents will tell you in detail about the day or week that their child changed. [iocdf.org]
Psychological symptoms may include: obsessive, compulsive, and repetitive behaviors separation anxiety, fear, and panic attacks incessant screaming, irritability, and frequent mood changes emotional and developmental regression visual or auditory hallucinations [healthline.com]
"It was a lot of screaming, a lot of hitting and kicking adults," said school principal AJ McCree. "When we would try and keep her safe in an isolated area, she would continue to elevate and elevate." [abcnews.go.com]
Workup
The five working criteria for the diagnosis of PANDAS are as follows [1]:
- Presence of OCD or tic disorder
- Prepubertal onset
- Episodic course and acute onset of symptoms and/or exacerbation
- Temporal association with group A streptococcal infection
- Association with neurologic abnormalities such as motoric hyperactivity or choreiform movements
Distinguishing PANDAS from tic disorder, OCD, or Sydenham chorea may be challenging, but recent studies suggest clinical and laboratory factors which aid in establishing the diagnosis [10] [11].
Treatment
Antimicrobial therapy indicated for the treatment of group A streptococcal infections irrespective of the presence of neuropsychiatric symptoms [3]. The treatment of the neuropsychiatric manifestation consists of standard management of children with OCD. Patients may benefit from intravenous immunoglobulin or plasma exchange, but data about immune modulating therapy is limited [12] [13].
Prognosis
The prognosis of PANDAS is unknown.
Etiology
Streptococci are gram-positive, nonmotile, non-spore-forming cocci. Group A Streptococci cause acute inflammatory infections (eg. pharyngitis, impetigo, necrotizing fasciitis, etc.), as well as postinfectious, immune-mediated conditions in humans [4]. Cases of PANDAS are associated with group A streptococcal infections, at least temporally. The disorder seems to develop due to cross-reactive antibodies produced in response to molecular mimicry, causing basal ganglia dysfunction. Due to the high incidence of group A streptococcal infections in the pediatric population and GAS carriage, the exact relationship between PANDAS and group A streptococcal infection is difficult to establish [5].
Epidemiology
The incidence and prevalence of PANDAS are not established, but it seems to be a rare disorder. Males are more commonly affected, but the reason is unknown.
Pathophysiology
The proposed pathophysiology of PANDAS includes group A streptococcal infections, abnormal immune responsivity and genetic susceptibility leading to central nervous system manifestations [6]. However, this hypothesis has yet to be proven.
Prevention
Since the exact pathogenesis of PANDAS is unknown, the potential benefit of prophylactic antimicrobial therapy remains unclear.
Summary
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a rare pediatric disorder associated with obsessive-compulsive disorder and tic disorder. The first 50 cases were described by Dr. Susan Swedo in 1998 [1]. The five diagnostic criteria for the disorder are as follows [1]:
- Presence of obsessive-compulsive disorder (OCD) or tic disorder
- Prepubertal onset
- Episodic course and acute onset of symptoms and/or exacerbation
- Temporal association with group A streptococcal (GAS) infection
- Association with neurologic abnormalities such as motoric hyperactivity or choreiform movements
The proposed pathophysiology of PANDAS includes various factors - a group A streptococcal infection, an abnormal immune response and genetic susceptibility leading to central nervous system manifestations. This model was based upon the similarity to Sydenham chorea [2]. PANDAS is a clinical diagnosis and treatment frequently consists of standard management of group A streptococcal infection and OCD/or tic disorder [3].
Patient Information
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) is a rare condition occurring in children. It may be diagnosed when an obsessive compulsive disorder (OCD) and/or a tic disorder suddenly develops or worsens following a streptococcal infection. PANDAS usually first appears in childhood from age 3 to puberty. The exact cause and disease mechanism of PANDAS are not known, but the streptococcal infection is thought to trigger a misdirected immune response causing a reaction in the brain.
The presentation is usually dramatic and acute. Symptoms may include tics, obsessions, compulsions, anxiety, emotional lability, night-time fears, mood changes, hyperactivity, sleep disturbance, deterioration in math skills and handwriting and cognitive deficits. The diagnosis of PANDAS is made clinically with the aid of the following diagnostic criteria:
- Presence of OCD or tic disorder
- Prepubertal onset
- Episodic course and acute onset of symptoms and/or exacerbation
- Temporal association with group A streptococcal infection
- Association with neurologic abnormalities such as physical hyperactivity or jerky, unusual (choreiform) movements
Treatment consists of standard management of Group A streptococcal infection and OCD/or tic disorder including antibiotics, behavioral therapy or selective serotonin reuptake inhibitors (SSRIs). Plasma exchange or intravenous immunoglobulin may be beneficial in acute and severe cases.
References
- Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998;155(4):264–71.
- Swedo SE. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Mol Psychiatry. 2002;7 Suppl 2:S24-5.
- Swedo SE, Leonard HL, Rapoport JL. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) subgroup: separating fact from fiction. Pediatrics. 2004 Apr;113(4):907-11.
- Walker MJ, Barnett TC, McArthur JD, Cole JN, Gillen CM, Henningham A, Sriprakash KS, Sanderson-Smith ML, Nizet V. Disease manifestations and pathogenic mechanisms of Group A Streptococcus. Clin Microbiol Rev. 2014 Apr;27(2):264-301. doi: 10.1128/CMR.00101-13.
- Tan J, Smith CH, Goldman RD. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Canadian Family Physician. 2012;58(9):957-959.
- Dale RC, Heyman I. Post-streptococcal autoimmune psychiatric and movement disorders in children. Br J Psychiatry. 2002 Sep;181:188-90.
- Orefici G, Cardona F, Cox CJ, Cunningham MW. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes: Basic Biology to Clinical Manifestations]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-2016 Feb 10.
- Kovacevic M, Grant P, Swedo SE. Use of Intravenous Immunoglobulin in the Treatment of Twelve Youths with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Journal of Child and Adolescent Psychopharmacology. 2015;25(1):65-69. doi:10.1089/cap.2014.0067.
- Swedo SE, Seidlitz J, Kovacevic M, et al. Clinical Presentation of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections in Research and Community Settings. Journal of Child and Adolescent Psychopharmacology. 2015;25(1):26-30. doi:10.1089/cap.2014.0073.
- Murphy ML, Pichichero ME. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS) Arch Pediatr Adolesc Med. 2002;156(4):356–61.
- Murphy TK, Storch EA, Lewin AB, Edge PJ, Goodman WK. Clinical Factors Associated with PANDAS. The Journal of Pediatrics. 2012;160(2):314-319. doi:10.1016/j.jpeds.2011.07.012.
- Kovacevic M, Grant P, Swedo SE. Use of Intravenous Immunoglobulin in the Treatment of Twelve Youths with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Journal of Child and Adolescent Psychopharmacology. 2015;25(1):65-69. doi:10.1089/cap.2014.0067.
- Perlmutter SJ, Leitman SF, Garvey MA, Hamburger S, Feldman E, Leonard HL, Swedo SE. Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood. Lancet 354:1153–1158, 1999