Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 9th Edition
Diagnosing and Treating PANS/PANDAS
Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 9th Edition offers historical, diagnostic, treatment, and research summaries of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). The intent of the section is to equip pediatric infectious disease clinicians with the foundational knowledge to understand these immune mediated neuroinflammatory brain disorders. The section emphasizes the abrupt and dramatic onset of obsessive-compulsive behaviors and/or restrictive eating as indicators to test for streptococcal and other infections followed by appropriate treatment.
Positioned within the chapter on Group A, Group C and Group G β-hemolytic Streptococcal Infections, the PANS/PANDAS section covers the following key elements:
- Proposed pathogenesis: Summarizes research that suggests antibodies targeting Group A Streptococcal (GAS) bacteria interfere with dopamine receptors in the basal ganglia.
- Diagnostic criteria: Includes the PANDAS Physicians Network PANS/PANDAS diagnostic flowchart and underscores criteria such as abrupt symptom onset, temporal association with infection, and a neuropsychiatric manifestation.
- Treatment: Discusses treating the inciting infection, immunologic dysfunction, and symptoms. Suggests if the patient has acute exacerbations of tics or OCD symptoms, they should be evaluated for an acute infection caused by Group A Strep (GAS).
- Prevention of future recurrences of PANS/PANDAS: Use of prophylactic antibiotics is discussed. The textbook mentions: “families in which persistence or recurrence of streptococcal infection is a problem, simultaneous throat culture and culture of skin lesions of all (family) members and treatment of all who have positive results have been successful in eradicating the organism”. (p. 821)
- Past controversy: Acknowledges that the controversy surrounding PANDAS comes from different approaches by research teams. Highlights the need for further research to describe the pathogenesis of the disease and additional animal models to help determine the appropriate treatment for each individual.
- The broadening of PANDAS to PANS: Includes information about the modification of diagnostic criteria to include patients that are post puberty, experiencing an acute onset of Avoidant Restrictive Food Intake Disorder, and presenting with post infectious etiologies other than strep, This section recommends laboratory testing to aid in a “diagnosis of exclusion”.
- Impact of COVID-19 on PANS: Advises testing for COVID-19 as part of the evaluation of patients with suspected PANS.
Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 9th Edition establishes PPN as an authority in PANS/PANDAS evaluation guidelines and treatment recommendations. Access the featured flowcharts at www.pandasppn.org/flowchart.
Additional Commentary from the PANDAS Physicians Network
This textbook provides medical professionals a foundation for understanding PANS/PANDAS. However, a few additional key points would give clinicians a more comprehensive approach to diagnosing and treating their PANS/PANDAS patients.
- Antibiotic Options in Treating PANS/PANDAS: The textbook states “penicillin treatment failures of 20% to 40% or higher have been reported (in eradicating GAS),” (p.823) so clinicians may need to consider alternative antibiotics for their PANS/PANDAS patients particularly if symptoms do not improve. Antibiotics that treating medical professionals have found to be effective in treating PANS/PANDAS patients include azithromycin, Augmentin, and cephalosporins.
- Use of Anti-inflammatory Medication: Research on using anti-inflammatory medications (e.g. steroids and NSAIDs) to reduce neuroinflammation and alleviate symptoms (Spartz 2027, Brown 2017) is not covered in the treatment section. Anti-inflammatories have been shown to shorten flares and provide symptom relief.
- Highlight the Importance of Strep Testing with the Abrupt and Dramatic Onset of Neuropsychiatric Symptoms: Authors note the importance of performing strep tests on children when they present with an abrupt and dramatic onset of neuropsychiatric symptoms since early diagnosis and treatment are crucial to preventing long-term psychiatric issues and additional strep-related complications. Calling out more clearly that acute, severe onset of neuropsychiatric symptoms warrant testing for strep, would be helpful to the medical clinician.
Including these 3 elements would give clinicians a more complete and current approach to diagnosing and treating PANS/PANDAS, thus improving patient outcomes.