Learn about the connection between this rare condition and a common childhood illness.
- Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is thought to be an autoimmune disease presents with the sudden onset of obsessive compulsive behaviors in children.
- Nurses can play an important role in educating children and families about the disorder and helping them navigate the healthcare system as they seek care.
What is PANDAS?
What are the symptoms?
What are the risk factors?
How is it diagnosed?
- OCD and/or a tic disorder
- Abrupt onset of OCD
- Neurologic abnormalities
- Association with GABHS infection
- Prepuberal onset
PANDAS is rare, so sometimes the provider doesn’t make the connection between a GABHS infection and the onset of OCD symptoms. In many cases, the symptoms of GABHS have resolved or are simply overlooked because of concern about the more dramatic neurologic/behavioral changes.
With any sudden onset of OCD and other neurologic behaviors, a rapid antigen test and/or throat culture should be ordered to determine if the patient has an active GABHS infection. If no acute GABHS symptoms are present, two antistreptococcal antibody titers 4 to 6 weeks apart is recommended to determine if the child has had a recent infection.
The final diagnostic criterium is the child’s age at the onset of symptoms. As the name implies, PANDAS is a pediatric disorder; it affects children from 3 years old to puberty. Adults may experience immune-related OCD, but no cases have been reported in the literature.
What’s the treatment?
PANDAS treatment consists of antibiotics for the GABHS infection and management of the neuropsychiatric symptoms. Typically, OCD symptoms are managed with a combination of medications (usually a selective serotonin reuptake inhibitor [SSRI]) and cognitive behavioral therapy for 6 to 12 months after diagnosis. Children with PANDAS tend to be unusually sensitive to the side effects of SSRIs, so “starting low and going slow” (using low doses and making small incremental increases) is recommended. Anti-inflammatory medications such as ibuprofen or naproxen also may prove beneficial, especially for exacerbations such as fever and sore throat discomfort.
Although controversial, plasmapheresis (plasma exchange) or I.V. immunoglobin have been used to treat severe cases of PANDAS. Both treatments are invasive, have significant side effects, and pose a risk of infection; they’re not recommended for all cases of PANDAS.
Some children recover fully from PANDAS and others exhibit persistent neuropsychiatric symptoms. Currently, there’s no way to predict how each child will be affected by the disorder. Likewise, no preventive measures exist. Surgical removal of the tonsils hasn’t proven effective, and prophylactic antibiotics are controversial because they may lead to antibiotic resistance.
What’s the controversy?
GABHS is quite common in children and hasn’t always been diagnosed at the time of the sudden onset of OCD symptoms. This has caused some providers to be skeptical of the association between OCD symptoms and GABHS. To address this concern, pediatric acute-onset neuropsychiatric syndrome (PANS) has been identified. This broader syndrome includes the sudden onset of OCD without the clear link to GABHS. PANDAS is considered a subset of PANS.
The link between infection and mental or behavioral behaviors isn’t new. In the early 20th century, neurosyphilis was considered a general constitutional weakness. And peptic ulcer disease was considered to be the result of stress. But we now know both are caused by bacterial infections. Evidence suggests that PANDAS will follow suit.
What is nursing’s role?
Nurses play a role in identifying PANDAS and then providing patients and families with support and education.
OCD symptoms often appear after GABHS infection symptoms have resolved, so families don’t make the connection. Your comprehensive assessment can identify a recent sore throat or other GABHS symptoms in conjunction with the sudden onset of neurologic symptoms. You can then recommend testing for GABHS.
Because OCD and other neurologic symptoms develop suddenly in this disorder, they can be frightening to the child and family. You can provide education about the disorder and help families navigate the healthcare system to obtain the appropriate care, including a psychiatrist for medication treatment and a therapist for cognitive behavioral therapy.
Successful treatment depends on adherence. Encourage families to schedule and attend appointments and follow dosing instructions for prescribed medications. If an SSRI is prescribed, explain to the family that they shouldn’t abruptly stop the medication; treatment duration is 6 to 12 months and the provider will taper the medication dose.
Tap into your strengths
Nurses often develop strong relationships with patients. Nurses are knowledgeable about the healthcare system, spend a great deal of time with patients and their families, provide care and support beyond the basics, and are perceived as being honest and trustworthy. A family dealing with the challenges of a PANDAS diagnosis will benefit from your knowledge, care, and honesty.
Joyce O’Reilly is an instructor in the College of Graduate and Professional Studies at Franklin Pierce University in Portsmouth, New Hampshire.
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