A Common (Fatal) Mistake: PANS/PANDAS

Bella Abrahamsen
Aug 15
4 min read

Introduction

An 11-year-old boy with dyslexia and a learning disability was brought to the doctor due to sudden separation anxiety and intense rage two weeks after a case of febrile pharyngitis. Just four weeks after the anxiety appeared, symptoms of OCD also showed up, accompanied by chorea. A month following his initial symptoms, he started showing signs of anhedonia, insomnia, and nocturia, and his irritability led to violent outbursts, which further isolated him from his friends and family. His pediatrician ordered ASO, anti-DNase B, and azithromycin. The antibiotics de-escalated his OCD, and his chorea was gone entirely, but his inattentiveness remained, causing him to struggle in school. So, his pediatrician took him off his antibiotics to see what was wholly cured and what was not, and what they found was that all his previous symptoms came back almost immediately. Hence, his pediatrician put him back on the medication. About 2 years into this cycle of waxing and waning symptoms, he ultimately recovered. While he was still suffering from anxiety, among other things, he was better than he was a few months prior. To someone who doesn't know a lot about neurorheumatology or neurology in general, cases like these can be very confusing for patients and their families. What this boy had was a condition called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, or PANDAS. It's tough to treat, but it's even harder to diagnose, which is why a lot of children may be suffering from this condition, while it's right under our noses.

Characteristics and Cause of PANS/PANDAS

PANDAS is usually characterized by abrupt symptoms such as chorea, OCD, enuresis, anxiety, and dysgraphia, among other things. As described in the case study, there are periods of waxing and waning where the patient feels fine, then swings back full force into their obsessions and compulsions like a pendulum. PANDAS, specifically, is caused by strep throat. While PANS is very similar, there are some distinct differences. Something particular to PANS is that there are several causes other than a streptococcal infection. Also, the main emphasis of PANS is abrupt OCD; while in PANDAS, chorea is its MO. PANS encompasses a broader group of symptoms than PANDAS, so children are more likely to be diagnosed with PANS, but could still receive treatment that is specific to PANDAS. But even though most children are diagnosed with PANS, there is still that overlapping of symptoms, which causes an overdiagnosis of PANDAS, which I'll go more into depth about later.

While PANS/PANDAS is still severely understudied and neurologists are still trying to figure out the cause of these diseases, we can look to similar diseases to find out what may be happening. For example, Sydenham's chorea is similar to PANDAS in the way that it's caused by group A streptococcal infection in childhood that leads to rheumatic fever. Another reason why Sydenham's chorea is a reasonable basis for finding the cause of PANS/PANDAS is that both conditions highly affect the basal ganglia in the brain, causing autoimmunity. Going back to PANS, the cause goes beyond streptococcal infection and could be genetic, metabolic, or infectious, which broadens the playing field. While this makes it more difficult to prevent due to the multitude of potential causes, it does make it easier to diagnose compared to PANDAS and Sydenham's chorea.

But the facts are inconsistent. Because of new technology, as well as our understanding of the brain and mental disorders, we keep learning more and retiring older ideas, but alongside that, PANS/PANDAS shows up slightly different in everybody, which changes the course of the diagnosis and treatment plan, as well as how this affects our current understanding of these diseases.

Diagnosis & Treatment

While there is no diagnostic test to diagnose PANS/PANDAS accurately, the majority of diagnoses are based on how the symptoms present themselves and how they occur, rather than solely based on autoimmunity. Another critical factor when it comes to diagnosing is that PANDAS may be overdiagnosed. Because PANS & PANDAS are highly similar and only have a few, distinct differences, they are commonly misdiagnosed as each other, alongside other similar conditions like TS, Sydenham's chorea, PITANDs, and CANS.

The treatment for PANS/PANDAS is essentially the same for TS and OCD, and it also depends on the patient and the severity of their case. The most common treatment plans for patients are CBT and prescribing medications like SSRIs.

Controversy, Culture, & Conclusion

The idea of PANS/PANDAS is still heavily debated in the media and the medical world. A big reason for this is the fact that there is a lack of general understanding, even for doctors and licensed professionals. PANS/PANDAS technically falls under neurological and mental disorders. If you've taken an anatomy and physiology class or even a psychology class, PANS/PANDAS might be brought up. But it goes way deeper than that. PANS/PANDAS is more closely linked to neurorheumatology, which is a distinct study focusing on the interlapped portions of neurology and rheumatology. Neurorheumatology focuses mainly on inflammatory diseases in the nervous system, as well as autoimmune disorders. The reason why PANS/PANDAS is controversial and understudied is that the field is so niche, yet it has a significant impact on the lives of many. While this is a relatively new condition that is still being heavily studied, many people have taken on the role of researching it. A lot of this research is happening at the Mayo Clinic, Johns Hopkins Hospital, and the Brigham Multiple Sclerosis Center.

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Works Cited