PANDAS

Host: Deanna Minich, PhD, CNS, FACN, IFMCP

Guest: Karima Hirani, MD, MPH

In this cutting edge discussion, Drs. Karima Hirani and Deanna Minich discuss pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), honing in on its clinical presentation, assessment, and treatment options in both pediatric and adult patients.

PANDAS is thought to arise from the development of brain-reactive autoantibodies following infection by a group A streptococcus (GAS). PANDAS is an episodic condition typified by a sudden onset of obsessive compulsive disorder (OCD) and involuntary movement disorder (e.g., tics), usually following a strep infection. Other patients may not have a classical history of a strep infection, but have been asymptomatic carriers of the strep infection nonetheless.

PANDAS can meet the criteria for the broader condition, PANS, or pediatric acute-onset neuropsychiatric syndrome, which can have other infectious triggers (other than strep) and environmental triggers too. Clinical manifestation not only includes 1) abrupt onset of OCD but can also involve 2) severe food restriction. Concurrent to OCD or anorexia, there should also be at least 2 out of the 7 possible comorbid conditions:

• Anxiety
• Emotional lability and/or depression
• ADHD or sudden deterioration in school performance
• Irritability, aggression, or severe oppositional behaviors
• Behavioral (developmental) regression
• Sensory or motor abnormalities (e.g., tics)
• Somatic signs and symptoms (e.g., urinary frequency, enuresis, sleep disturbances)

Mostly seen in grade-school-age pediatric patients, PANS can also present during adolescence and even adulthood. Dr. Hirani shares how this cluster of symptoms can manifest in adults, reviewing a case of an adult male patient with OCD, anxiety, tic disorder, and sleep disturbances. His symptoms began in early childhood but was labeled ADHD at the time. Decades of incorrect diagnoses and treatments left this patient disabled. Broadening awareness of this condition in primary care and pediatrics is critical to providing relief to PANS/PANDAS patients.

PANS etiology is usually infectious or inflammatory, and treatment should be simultaneous with diagnosis. Dr. Hirani illuminates her diagnostic approach, including an infectious disease workup (including Lyme disease), along with assessments for nutritional status/deficiencies (e.g., omega-3s, vitamin D, CoQ₁₀, methylmalonic acid [MMA] to assess vitamin B₁₂ status, iron, zinc), food allergies or intolerance (e.g., gluten), gut dysbiosis, hormones (e.g., thyroid, adrenal, growth hormone), and environmental exposures (e.g., heavy metals, mold).

PANS/PANDAS treatments include conventional approaches (e.g., psychological, behavioral, pharmacological [antibiotics, NSAIDs, corticosteroids]) and alternative modalities – diet therapy, targeted nutritional therapies, ozone therapy, low dose immunotherapy (LDI), low dose allergen (LDA) immunotherapy, and homeopathy.

By reducing the inflammatory burden of the diet (e.g., limiting exposure to sugar, hybridized foods, and pesticide residues), Dr. Hirani has observed symptom improvement in her PANS/PANDAS patients. She partners with them to implement a gluten-free, casein-free, low sugar or no sugar, organic, non-GMO, corn-free, and soy-free dietary approach. Methylation imbalance and defects also exist in this patient population, so Dr. Hirani shares that subcutaneous methylcobalamin (vitamin B₁₂) injections have also proven successful in her patient group.

Each patient is unique, including the PANS/PANDAS patient, so a personalized treatment approach will produce the most significant clinical impact.

This Metagenics Institute LIVE broadcast took place live January 22, 2019 on the Metagenics Institute Facebook page.

Case Study Citation

Karima H. Case report. Minor ozonized autohemotherapy in a 2 year old boy with speech delay and cytomegalovirus infection: a case report. Revista Espanola de Ozonoterapia. 2018;8(1):165-169.

Other PANS/PANDAS Resources

PANDAS Physicians Network. https://www.pandasppn.org/ppn-pans-diagnostic-guidelines/. Accessed January 21, 2019.

Orefici G et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Streptococcus pyogenes: basic biology to clinical manifestations. https://www.ncbi.nlm.nih.gov/books/NBK333433/. Accessed January 21, 2019.

Multiple authors. J Child Adolesc Psychopharmacol. 2017;27(7). https://www.liebertpub.com/toc/cap/27/7. Accessed January 21, 2019.

Swedo SE et al. Overview of treatment of pediatric acute-onset neuropsychiatric syndrome. J Child Adolesc Psychopharmacol. 2017;27(7):562-565.

Thienemann M et al. Clinical management of pediatric acute-onset neuropsychiatric syndrome: Part I- Psychiatric and behavioral interventions. J Child Adolesc Psycholpharmacol. 2017;27(7):566-573.

Frankovich J et al. Clinical management of pediatric acute-onset neuropsychiatric syndrome: Part II- Use of immunomodulatory therapies. J Child Adolesc Psycholpharmacol. 2017;27(7):574-593.

Cooperstock MS et al. Clinical management of pediatric acute-onset neuropsychiatric syndrome: Part III- Treatment and prevention of infections. J Child Adolesc Psycholpharmacol. 2017;27(7):594-606.

Calaprice D et al. A survey of pediatric acute-onset neuropsychiatric syndrome characteristics and course. J Child Adolesc Psychopharmacol. 2017;27(7):607-618.

PANDAS and Lyme disease: review and clinical overlap

Rhee H et al. Lyme disease and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an overview. Int J Gen Med. 2012;5:163-174.