PANDAS- Can Strep Cause Psychiatric Problems in Children?

The following article can be found in Understanding Your Child’s Health by Susan K Schulman MD., which will be available in July, 2009 (Hamodia Treasures, distributed by Israel Book Shop)

We have known for many years that the bacteria known as Beta Hemolytic Group A Streptococcus causes sore throats with fever and swollen lymph nodes in the neck.

We also know that there are rare and serious complications that can occur when this infection is left untreated. These are Acute Rheumatic Fever (inflammation of the heart, joints, skin and nervous system), and Acute Glomeruo Nephritis (a kidney problem). Milder forms of arthritis are also often traced to strep

These conditions arise when the child’s immune system produces excess amounts of antibody in an effort to fight the Strep. This excess antibody can mistakenly attack the heart, brain, joint lining or kidneys, causing disease. The fear of these complications has led to the development of throat cultures and fast Strep tests that can be performed in the office or lab. When Group A Beta Strep is identified, antibiotics are prescribed.

It has long been noted that about 50% of cases of rheumatic fever had no history of sore throat or fever prior to the attack. It is assumed that not all Strep infections cause an identifiable illness, and not all are in the throat. Group A Strep can cause sinusitis, ear infections and some other infections. These often go undiagnosed and untreated because they do not usually cause fever and systemic illness.

In 1998 Dr. S. Swedo from the National Institute of Mental Health described another pediatric problem caused by step-Obsessive Compulsive Disorder. She described a group of patients who developed the psychiatric symptoms during or after a Strep infection. These children were all pre-pubertal and did not respond to the usual psychiatric medications. They all had extremely elevated levels of the anti-Strep antibody DNASE B. Some of them improved dramatically after treatment with antibiotics.

Since that time, other neuro-psychiatric disorders in young children- including tics, Tourette’s, anxiety disorders and major behavior changes-have been attributed to Strep infections. The syndrome was labeled PANDAS (Pediatric Autoimmune Neuro-psychiatric Disorders Associated with Strep).

There are large studies going on now in major medical centers to study PANDAS. They are trying to determine if the patients really do improve on antibiotics and whether they need long-term prophylactic doses to prevent relapse. Meanwhile, many pediatricians are considering Strep when one of their young patients suddenly develops a neuro-psycychiatric disorder.

The symptoms can vary in different children. The most obvious one is tics, which are involuntary facial and body movements such as eye-rolling, grimacing or tapping hands or feet. Other symptoms include involuntary noises such as snorting, squeaking, coughing, or even yelling.

Some of the children develop strange habits such as running to the bathroom every few minutes in fear of wetting themselves. Some have more classic obsessive thoughts such as fear of germs or guilt over trivial transgressions, and compulsive behaviors such as hand-washing or even excessive davening.

Sometimes the child will have a sudden change of personality or behavior, for example, a naturally even-tempered child becoming irritable, impulsive, oppositional or obnoxious.

Some of the children develop severe anxieties that interfere with normal functioning, for example, fear of leaving home. Many of these children experience joint pains and headaches along with the change in behavior.

When a parent complains of a dramatic change in a child, it is now known that this child needs a throat culture and a blood test for DNASE B antibody. If either test result is abnormal, the diagnosis of PANDAS should be considered.

The treatment for these children should be a course of antibiotics. Which specific antibiotic is not well delineated Many doctors are using Amoxicillin or Keflex, however, there is some evidence that Zythromax can result in a quicker and more dramatic return to normal behavior.

The pediatric psychiatric community is not yet in tune with this diagnosis. Any pre-pubertal child who experiences deterioration in his or her psychiatric functioning should be tested for DNASE B antibody and should have a throat culture. If either of these test results is abnormal, a course of antibiotics (in my experience, Zythromax) should be attempted before a psychiatric referral is made, since it often results in cure.

PANDAS is still a new and somewhat unproven concept. The fact is, however, that in our community we have seen many examples that seem to fit the diagnosis and respond well to this “unusual” treatment.

The problem can recur with subsequent strep infections. When the PANDAS behavior starts to become evident again, another treatment with antibiotics usually resolves the problem. Some doctors feel that after a recurrence, a 6-to-12 month course of low-dose Amoxil two times a day, or Zythromax, once a week, should be given to prevent strep infections.

Even though we, as pediatricians, are trying hard not to use antibiotics unnecessarily, this is one instance when we must consider treatment as critically important. Although most kids with tics and even childhood OCD improve with time, the PANDAS symptoms can, if left untreated, become permanent.

It is important to realize that everybody suffers when a PANDAS child is suffering- the parents, the siblings,the classmates, the teachers and the friends.
This is, admittedly, a strange new idea, but for the parents of a child with PANDAS the relief experienced when their child returns to normal is indescribable.

Key Points

• Strep can cause complications in some children who are overproducers of antibodies.
• One of these conditions is PANDAS-Pediatric, Autoimmune, Neuropsychiatric Disorders Associated with Strep.
• Acute onset of tics, Tourettes, OCD or other psychiatric symptoms in a child should trigger an evaluation for Strep.
• Antibiotics can eliminate the tics and the psychiatric symptoms in some children.