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Would you suspect a strep throat infection was to blame if your child suddenly developed OCD, tics, anxiety, and mood swings? Neither would I. But this is exactly what happens in PANDAS.

What would you do if your child suddenly developed odd symptoms — like anxiety, obsessive compulsive behavior, tics, separation anxiety, and episodes of rage? If you're anything like your typical modern parent, you'd be worried sick, Google the symptoms, and start looking around for reputable local psychologists or psychiatrists rather rapidly. Indeed, in the presence of these symptoms, you wouldn't be at all unlikely to end up with one or more mental health diagnoses. But what if the origins of your child's symptoms could be found somewhere completely different, in something as common as strep? Enter PANDAS. 

What Is PANDAS?

Short for the rather wordy Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, PANDAS is a rare autoimmune response to a streptococcal infection. First spotted in the late 1990s, PANDAS is both rare and new — making diagnosis tricky. It can be diagnosed clinically (meaning there aren't specific tests that look for the disorder) when neuropsychiatric symptoms show up shortly and suddenly after a strep throat infection. 

The secret to PANDAS' cause lies in the behavior of the strep bacteria. By hiding in the host's body in the form of molecules that are nearly identical to the body's own cells, strep manages to avoid detection for quite a while. Once the immune system notices its presence, it starts making antibodies to attack the invader. However, because the strep bacteria's molecules can be so similar to those found in the body's own cells, those cells may be attacked as well. Some of those cells can be in the brain, and when they are attacked, neuropsychiatric symptoms can make their appearance.

PANDAS is considered to be a pediatric disorder, meaning it typically occurs in children between the ages of three and 12 years old. Surreal reactions to strep infections haven't been observed in older people, though it's possible teenagers could develop PANDAS as well.

PANDAS Symptoms

The diagnostic criteria for PANDAS are as follows:

  • The person suspected of having PANDAS has to be between three and 12 years old.
  • As PANDAS can only be diagnosed in individuals with group A Beta-hemolytic streptococcal infection , a positive test for strep throat or previous scarlet fever is required.
  • The symptoms of Obsessive Compulsive Disorder, a tic disorder, or both have to be present. There will also be hyperactivity or involuntary motor movements in most cases.
  • The symptoms develop suddenly or worsen abruptly.
The symptoms of Obsessive Compulsive Disorder can vary a lot. Obsessive and intrusive thoughts, like a fear of germs, an inner need for focus and organization, and the thought that failing to achieve certain things will cause harm to other people, are a part of OCD. Compulsive behaviors include counting things, washing one's hands over and over again, checking whether the door is locked or homework is done repeatedly, and feeling the strong need to do things in numbered patterns. 
 
Tic disorders vary from simple to complex. They may consist of nothing more than a slight involuntary movement of facial muscles, or they could involve swinging an arm continuously while waiting for the bus. Some tics are verbal. Sufferers may make a particular noise or involuntarily repeat sentences.
 
In addition to these characteristic symptoms, children with PANDAS may also display ADHD symptoms like being fidgety and hyperactive, experience separation anxiety, flow into sudden bouts of rage or have mood swings, experience sleeping difficulties including sometimes bed-wetting, and lose fine motor skills they previously possessed, such as the ability to write neatly. Joint pains are another symptom of PANDAS.
 
The symptoms of PANDAS aren't minor. They have a very sudden onset that makes it completely clear that something very serious is going on. Some children with PANDAS completely cease normal functioning, while others struggle through the day, but with very clear hindrances.

How PANDAS Is Diagnosed

PANDAS: Coming To A Diagnosis May Be A Long Path

PANDAS is rare, while strep throat is very common indeed. As such, it's important to realize that not every child who displays symptoms of OCD, anxiety, and tics and also has a history of strep throat will have PANDAS by any means. The diagnosis of PANDAS is currently made clinically. That means that, though a throat swap and test for strep is a required part of the diagnostic process and an A strep ASO and D-nase Titer test is often helpful, diagnosis is very much open to interpretation in that there is no test that specifically identifies PANDAS.
 
In order to qualify for the diagnosis of PANDAS, a very clear connection between strep and the symptoms has to be identified. That means the symptoms develop very soon after the initial infection. 

Not every doctor will have seen PANDAS before, and even those who have may be reluctant to diagnose it even if the symptomatic picture fits. In this day and age, it isn't rare for parents to explore the possible causes of their child's symptoms online. It can happen that you suspect PANDAS before your doctor does. What should you do if your doctor doesn't want to consider the diagnosis of PANDAS, but you are pretty convinced that it is an option? Seeking a second opinion is a good course of action here. Some parents specifically contact the PANDAS Network to look for a doctor who has experience with the syndrome, and you can also look for local doctors who have dealt with PANDAS before via the internet. 

Treating PANDAS

Treatment options depend on whether the strep infection is still present or not. If a strep throat culture comes back positive, the appropriate antibiotics will cure the infection, often allowing symptoms to wane pretty quickly by themselves. Where a throat culture is negative, clinicians should look for occult strep infections, like those present within the sinus. 

If an occult strep infection is present — something that's rare — antibiotics will take longer to work properly. 

Once the strep infection is gone, the neuropsychiatric symptoms associated with PANDAS may still persist. While some parents report that the symptoms of PANDAS improve almost immediately after a course of antibiotics, and others notice a gradual improvement with time, some children continue to suffer with OCD symptoms, tics, and other related behaviors.

Because symptoms may persist, children diagnosed with PANDAS will often benefit from Cognitive Behavioral Therapy to tackle their OCD symptoms. SSRIs may also help here, but the recommendation is to start at low doses due to possible side effects. As for tics, those can be treated medicinally as well. 

Many physicians will recommend that a child previously diagnosed with PANDAS also remains on prophylactic antibiotics for five years after diagnosis, in order to prevent recurrence. 
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  • Photo courtesy of myfuturedotcom: https://www.flickr.com/photos/myfuturedotcom/6052951507/
  • Photo courtesy of jinterwas https://www.flickr.com/photos/jinterwas/5307033111/

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