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Neuropsychiatric changes possibly linked to strep explored by doctors

Doctors say a team approach is needed for these complex, difficult-to-diagnose disorders

Boy getting throat checked
This image from the Centers for Disease Control and Prevention shows a doctor taking a throat swab from a boy suspected of having a strep infection.
Helen Adams | | January 10, 2018

Doctors at MUSC Children’s Health are working together to refine their approach to evaluating children suspected of having PANDAS, or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.

Developmental-behavioral pediatrician Michelle Macias said it’s a controversial condition that requires a team approach. “We have an interdisciplinary team where we evaluate kids with a combination of developmental, learning and behavioral/mental health problems. On a few occasions, we have considered PANDAS or PANS as a potential exacerbating factor of the child’s presentation.”

According to the National Institute of Mental Health, a child may be diagnosed with PANDAS when he or she suddenly develops obsessive compulsive disorder and/or tics after a strep infection, or when OCD and tic symptoms suddenly get worse after strep. The strep infection may involve strep throat, perianal strep or scarlet fever.

Why would strep cause neuropsychiatric changes? The NIMH reports that strep bacteria hide from the immune system by putting molecules on their cell walls that look like molecules from other parts of the body, including brain tissues.

When the immune system finally spots the strep bacteria, it goes on the attack. The trouble is, it may not just target the invader — it may also attack molecules in the brain that the strep was mimicking. And that, according to the NIMH, may cause OCD, tics and other symptoms.

Macias said if a child has PANDAS, the appearance of those symptoms is usually dramatic. “The diagnosis involves an abrupt onset and episodic course of symptoms. It’s partially a diagnosis of exclusion. Any diagnosis that doesn’t have clear-cut symptoms/ symptom cluster, to call it a syndrome, it’s always going to be controversial.”

PANDAS is a subset of PANS, which stands for pediatric acute-onset neuropsychiatric syndrome. While PANDAS is linked specifically to strep, PANS has a longer list of potential triggers, including infections and metabolic disturbances. Both PANDAS and PANS are suspected of causing some children to suffer from depression, emotional lability, anxiety and/or restrictive eating patterns.

Treatments include antibiotics, if there’s still an infection, along with cognitive behavioral therapy and psychiatric medications.

Macias said doctors from multiple areas at MUSC Health are involved with considering the best approaches, including specialists in psychiatry, developmental pediatrics, rheumatology, infectious diseases and neurology.

“I certainly always want to empathize with the parents and respect where the parents are coming from. These kids are having major problems, so if there’s anything that could help attenuate symptoms, the parents would want to do it. No matter what, these symptoms still have to be treated. So if the child has OCD or tics or whatever problem — that still needs to be treated. The question is the etiology, and that’s what is so unclear.”

Strep throat in children and teens (SC Public Radio, Oct. 23, 2017) 

Girl winning battle with anxiety with a little expert help (MUSC News, July 8, 2015)

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