Medical Overview

The term PANDAS was established by Swedo and colleagues in 1998 to characterize a subset of childhood OCD and tic disorders thought to be triggered by group A beta hemolytic Streptococcus (GABHS) infection (Swedo et al. 1998). Swedo and colleagues suggested that the GABHS infection triggers an autoimmune response with antibodies targeted against GABHS that cross-react with neuronal cells to produce inflammation in the CNS, specifically in the basal ganglia. This inflammation is thought to lead to the onset of OCD and tic behaviors, including Tou-rette's syndrome, which are the characteristic symptoms of PANDAS (Perlmutter et al. 1999).

A diagnosis of PANDAS is made based on the following diagnostic criteria: 1) presence of DSM-IV-TR (American Psychiatric Association 2000) criteria for OCD, tic disorder, or both; 2) onset of symptoms before puberty; 3) episodic course of symptom severity, with an abrupt onset of symptoms and sudden exacerbation of OCD and/or tic behavior; 4) temporal association of psychiatric symptoms with GABHS infection (e.g., OCD and/or tic behaviors are linked to positive throat culture and/or elevated anti-GABHS antibody titers); and 5) presence of neurological abnormalities (e.g., motor hyperactivity, adventitious choreiform movements, or tics) during symptom onset and subsequent exacerbations. Patients with OCD as their primary psychiatric symptom may have normal results on neurological examination, especially during periods of remission (Swedo et al. 1998).

To make a definitive diagnosis of PANDAS, strep-tococcal infections associated with symptom exacer bation and declining titer levels correlated with symptom remission must be demonstrated (Swedo et al. 1998). A throat culture should be performed during onset or exacerbation of psychiatric symptoms to confirm GABHS infection because not all children with GABHS infection have a sore throat (Murphy and Pichichero 2002; Snider and Swedo 2004). Additionally, not all exacerbations of PANDAS are linked with GABHS infection. Viral infections may also trigger PANDAS reoccurrence; the primary immune response is specific, directed against a particular epitope in the GABHS, but the secondary responses may be more generalized and targeted against a wider range of antigens (Swedo et al. 1998).

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