PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

February 8, 2017

PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. The term is used to describe a subset of children who have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette’s Syndrome, and in whom symptoms worsen following strep infections such as “Strep throat” and Scarlet Fever.

The symptoms are usually dramatic, happen “overnight and out of the blue,” and can include motor and/or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable, experience anxiety attacks, or show concerns about separating from parents or loved ones.

PANDAS was first discovered in 1998 by Dr. Susan Swedo during a Pediatric Obsessive Compulsive Disorder study when it was found some children’s OCD behaviors began shortly after a strep infection. In any autoimmune disease, it is the consequence of a misguided immune response against self-antigens by autoantibodies that results in the damage of specific organs. In the case of PANDAS, the child’s brain is being attacked.

In every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However in Rheumatic Fever, the antibodies mistakenly recognize and “attack” the heart valves, joints, and/or certain parts of the brain. This phenomenon is called “molecular mimicry”, which means that proteins on the cell wall of the strep. bacteria are similar in some way to the proteins of the heart valve, joints, or brain. Because the antibodies set off an immune reaction which damages those tissues, the child with Rheumatic Fever can get heart disease (especially mitral valve regurgitation), arthritis, and/or abnormal movements known as Sydenham’s Chorea or St. Vitus Dance. In PANDAS, it is believed that something very similar to Sydenham’s Chorea occurs. One part of the brain that is affected in PANDAS is the Basal Ganglia, which is believed to be responsible for movement and behavior. Thus, the antibodies interact with the brain to cause tics and/or OCD, instead of Sydenham Chorea.


The strep bacteria is a very ancient organism which survives in its human host by hiding from the immune system as long as possible. It does this by putting molecules on its cell wall that look nearly identical to molecules found on the child’s heart, joints, skin, and brain tissues. This is called “molecular mimicry” and allows the strep bacteria to evade detection for a time.

However, the molecules on the strep bacteria are eventually recognized as foreign to the body and the child’s immune system reacts to them by producing antibodies. Because of the molecular mimicry, the antibodies react not only with the strep molecules, but also with the human host molecules that were mimicked.

The cross-reactive antibodies then trigger an immune reaction that “attacks” the mimicked molecules in the child’s own tissues. Studies show that some cross-reactive “anti-brain” antibodies target the brain, causing OCD, tics, and the other neuropsychiatric symptoms of PANDAS.

A leaky gut, whereby undigested proteins, pathogens, and toxins can pass into the bloodstream provoking inflammation and immune reaction generally underlies autoimmunity. It also makes absorption of nutrients difficult which adds to immune dysfunction. Over 70% of the immune system is in the gut.

Who is at risk?

ANDAS is a rare condition. It is believed that approximately one in 2,000 children are affected, though the diagnosis may be overlooked due to some of the common symptoms associated with the disease. In fact, there are some researchers who recommend including PANDAS in a category of other disorders which include similar neuropsychiatric symptoms called CANS (childhood acute neuropsychiatric symptoms) or PANS (pediatric acute-onset neuropsychiatric syndrome).

PANDAS is considered a pediatric disorder and typically first appears in childhood from age 3 to puberty. Reactions to strep infections are rare after age 12, but the investigators recognize that PANDAS could occur (rarely) among adolescents. It is unlikely that someone would experience these post-strep neuropsychiatric symptoms for the first time as an adult, but it has not been fully studied.

It is possible that adolescents and adults may have immune-mediated OCD, but this is not known


Children with PANDAS seem to have dramatic ups and downs in their OCD and/or tic severity. Tics or OCD which are almost always present at a relatively consistent level do not represent an episodic course. Many kids with OCD or tics have good days and bad days, or even good weeks and bad weeks. However, patients with PANDAS have a very sudden onset or worsening of their symptoms, followed by a slow, gradual improvement. If they get another strep infection, their symptoms suddenly worsen again. The increased symptom severity usually persists for at least several weeks, but may last for several months or longer. The tics or OCD then seem to gradually fade away, and the children often enjoy a few weeks or several months without problems. When they have another strep throat infection, the tics or OCD may return just as suddenly and dramatically as they did previously. Symptom onset includes Primary ONSET of OCD and/or Severe Anxiety along with at least two other following symptoms –

  • Obsessive compulsive disorder
  • Tics (motor and verbal)
  • Sensory Processing Disorder
  • Age regression
  • Choreiform movements
  • Hyperactivity
  • Mood fluctuations
  • Changes in handwriting
  • Personality changes
  • Oppositional Defiant Disorder
  • Deterioration in math skills
  • Separation anxiety
  • Depression
  • Rages
  • Urinary incontinence, urgency and increased frequency (daytime or nighttime)
  • Anorexia


Treatment options for children who are diagnosed with PANDAS are emerging.  The most common initial intervention is a combination of cognitive behavioral therapy (CBT), SSRI medications, antibiotics (with a minimum trial of 4-5 weeks), and supplements (such as vitamin D, Omega 3, and probiotics).  While some children may exhibit an improvement in symptoms when using antibiotics or SSRI medications, it is also often recommended to consult with a psychologist that is experienced in this area.

Often, the treatment protocol for PANDAS includes exposure and ritual prevention (ERP), which is a specific type of CBT. Using ERP, the psychologist helps the child to understand their obsessions, compulsions, and movements, how to challenge these symptoms as well as related anxiety. It is also important that the child learn specific therapeutic and stress management skills to practice in between sessions.  ERP is also used to lessen the probability and severity of future exacerbations.

doctor may prescribe penicillin, amoxicillin (Amoxil), azithromycin (Zithromax), or another antibiotic. For severe and refractory symptoms, the use of other treatments aimed at controlling the immune response have been studied and found to be effective. These include the use of intravenous immunoglobulin, steroids, and plasmapheresis (plasma exchange therapy in which blood is withdrawn from an individual and the liquid portion is removed and replaced and the blood is transfused back into the individual).

Alternative Treatment

  • N-acetyl cysteine/NAC has been found to help with some OCD symptoms.
  • Natural anti-inflammatories, such as Curcumin, can be also useful.
  • Natural antibiotics/anti-virals such as Olive Leaf Extract/OLE and Grapefruit Seed Extract/GSE.
  • Omega-3 supplements can support healthy brain function.
  • Using probiotics is very important to ensure optimum gut flora environments are not depleted during antibiotic treatments and for good overall immunity. As a precaution, avoid any that contain the streptococcus thermophilus strain.



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