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Unraveling the Mystery of PANDAS

Updated: Jan 27

Unraveling the Mystery of PANDAS : Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infection

Introduction

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is a complex medical condition that affects children, particularly between the ages of 3 and 12. PANDAS is characterized by a sudden onset of neuropsychiatric symptoms following a streptococcal infection, which has made it the subject of intense research and clinical interest. In this article, we should throughly devel into the pathophysiology, symptoms, diagnosis, and treatment of PANDAS, and compare it with rheumatic fever, sydenham chorea, and scarlet fever to better understand its unique and distinguishing characteristics.

Pathophysiology

The pathophysiology of PANDAS revolves around an autoimmune response triggered by certain streptococcal infections, particularly Group A Streptococcus (GAS). In genetically susceptible individuals, the immune system mounts an attack against the invading bacteria by producing antibodies. However, in PANDAS, these antibodies cross-react with specific brain tissues, particularly in the basal ganglia, a region responsible for regulating movements and behaviours in childrens.



The cross-reactive antibodies target brain proteins, leading to inflammation and dysfunction in the basal ganglia. This autoimmune response disrupts neural circuits, which results in the sudden onset of neuropsychiatric symptoms in affected children.

Symptoms

PANDAS typically manifests with a rapid and dramatic onset of symptoms, usually within days to weeks after a streptococcal infection. The symptoms are as follows :

  1. Obsessive-Compulsive Disorder (OCD): Children may develop intense and intrusive obsessions and compulsions, such as repetitive handwashing, counting, or performing rituals.

  2. Tics: Motor and vocal tics, similar to those seen in Tourette's syndrome, can emerge, causing involuntary and sudden movements or vocalizations.

  3. Emotional Changes: Mood swings, irritability, and emotional lability may occur, leading to sudden onset and outbursts of anger or sadness.

  4. Behavioral Regression: Some children may experience a sudden regression in behavior, such as bedwetting, separation anxiety, or difficulties with tasks they have previously mastered.

  5. Cognitive Decline: PANDAS can cause problems with concentration, attention, and memory, affecting academic performance in previously normal children.

Diagnosis

Diagnosing PANDAS can be challenging due to its overlapping symptoms with other neurological and psychiatric disorders. However, specific criteria have been proposed to aid in its diagnosis:

  1. Presence of OCD and/or Tics: The child must exhibit obsessions, compulsions, and/or motor/vocal tics.

  2. Pediatric Onset: Symptoms should appear before puberty, typically between ages 3 and 12.

  3. Episodic Course: Symptoms should follow a relapsing-remitting pattern, with acute worsening triggered by streptococcal infections.

  4. Temporal Association with Streptococcal Infection: There should be a clear link between symptom onset or exacerbation and a recent streptococcal infection, positive throat culture and/or elevated Anti GAS titres (anti DNAse B or ASO)

  5. Neurological Abnormalities: Children may display neurological abnormalities during clinical examination.


Treatment

The treatment of PANDAS aims to reduce inflammation, modulate the immune response, and manage neuropsychiatric symptoms. The primary treatment approaches include:

  1. Antibiotics: Early and appropriate treatment of streptococcal infections with antibiotics, such as penicillin or amoxicillin, may help prevent or reduce the severity of PANDAS symptoms.

  2. Immunomodulatory Therapy: In severe cases, therapies that modify the immune response, such as intravenous immunoglobulin (IVIG) or plasmapheresis, may be considered to target the cross-reactive antibodies.

  3. Symptomatic Relief: Medications like selective serotonin reuptake inhibitors (SSRIs) may be prescribed to alleviate OCD and mood-related symptoms.

  4. Behavioral and Cognitive Therapies: Psychotherapy and behavioral interventions can be beneficial in managing OCD and other behavioral symptoms.



Comparisons with Rheumatic Fever, Sydenham Chorea, and Scarlet Fever

Rheumatic Fever: Like PANDAS, rheumatic fever is an autoimmune disorder triggered by streptococcal infections. However, rheumatic fever primarily affects the heart, joints, skin, and brain (Sydenham chorea). In contrast, PANDAS primarily targets the brain, leading to neuropsychiatric symptoms. The autoimmune response in rheumatic fever is directed against heart and joint tissues, not the basal ganglia as in PANDAS.

Sydenham Chorea: Sydenham chorea is another post-streptococcal autoimmune disorder characterized by involuntary, purposeless movements, primarily affecting the limbs, face, and trunk. Unlike PANDAS, Sydenham chorea predominantly involves motor function without significant neuropsychiatric symptoms like OCD or cognitive decline.

Scarlet Fever: Scarlet fever is a streptococcal infection characterized by a distinct rash caused by a bacterial toxin. Unlike PANDAS, it does not involve an autoimmune response or neurological symptoms.


Conclusion

PANDAS remains a captivating area of research. Its sudden onset of neuropsychiatric symptoms following streptococcal infections makes it a challenging condition to diagnose and manage. By understanding its pathophysiology, recognizing its symptoms, and implementing appropriate treatments, clinicians can offer much-needed relief to affected children and improve their quality of life. Furthermore, comparing PANDAS with other streptococcal-associated conditions like rheumatic fever, Sydenham chorea, and scarlet fever helps to elucidate its unique features, ultimately advancing our knowledge and enhancing patient care.

-Dr. Amiya Ameer


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