Dr. Kumar’s Take on PANDAS
This study shows that PANDAS can appear suddenly in children after a mild group A strep infection and that treating the infection quickly often leads to rapid symptom relief. The real opportunity is early recognition: a child with abrupt OCD, separation anxiety, tics, or behavioral shifts should trigger evaluation for PANDAS with throat testing and prompt antibiotic therapy.
Key Takeaways
✔ PANDAS episodes were prospectively linked to recent group A streptococcal infections in a primary care setting.
✔ Antibiotics at the first PANDAS flare led to symptom improvement usually within two weeks.
✔ Recurrences of PANDAS aligned with new strep infections and again responded to antibiotics.
✔ More prior strep exposures before onset predicted a relapsing PANDAS course.
✔ Strep triggers were often clinically mild, so PANDAS can be missed without active suspicion.
Actionable Tip
When a child has sudden severe neuropsychiatric changes, consider PANDAS even if there is no classic sore throat. Get throat culture or rapid strep test and, if positive or strongly suspected, treat with a penicillin or cephalosporin while monitoring behavioral response over the next 1 to 3 weeks.
Symptoms of PANDAS
PANDAS usually shows up suddenly and can look like a mix of behavioral, emotional, and movement changes. Key symptoms to watch for include:
- Abrupt onset of obsessive-compulsive behaviors (new severe rituals, intrusive thoughts, excessive checking or washing)
- Tics (sudden jerks, eye blinking, facial movements, or vocal sounds)
- Separation anxiety that is age-inappropriate or suddenly much worse, especially in the mornings
- Mood swings or emotional lability (rapid shifts from calm to upset or tearful without a clear trigger)
- Changes in personality or behavior such as irritability, oppositional behavior, or regression in function
- Attention or concentration changes that look like new ADHD symptoms
- Unusual urinary symptoms (daytime urgency or frequency without infection) linked to compulsive behaviors
- Sleep disturbance related to anxiety or new worries
- Decline in school performance or withdrawal tied to the sudden behavioral changes
Red flags that make PANDAS more likely: the sudden, explosive appearance of these symptoms, a history of recent group A strep infection (even mild), and symptom flares that recur with new strep exposures.
Study Summary
Over a three-year period, 12 school-aged children with abrupt onset of behaviors consistent with PANDAS were identified in a primary care pediatric practice. Most had evidence of recent group A streptococcal infection. Treatment of the sentinel episode with appropriate antibiotics led to rapid resolution of symptoms. All recurrences were tied to new strep infections, and those also improved with therapy. Children with a higher number of prior strep infections had more frequent and persistent PANDAS flares.
Study Design
This was a prospective observational series from 1998 to 2000. Children with explosive new behavioral symptoms (OCD, tics, separation anxiety, or ADHD-like features) were evaluated for PANDAS by testing for group A beta-hemolytic streptococcal infection via throat culture or rapid antigen detection, as well as streptococcal antibody titers when needed. Confirmed PANDAS episodes received 10 days of antibiotics effective against strep, and patients were followed for resolution and recurrence.
Results
- Most PANDAS episodes had a clear temporal relationship to recent streptococcal infection.
- Antibiotic treatment produced rapid improvement, with mean symptom resolution around 14 days.
- Six of 12 children had at least one recurrence; each recurrence coincided with a new confirmed strep infection.
- Prior frequency of strep infections correlated with more relapsing and severe PANDAS.
- Triggers were often subtle infections lacking strong fever or classic signs, making clinical detection without testing unreliable.
Proposed Mechanism
The consistent timing of behavioral flares with strep infections, rapid reversal with eradication, and recurrence only with new infections support a strep-linked neuroimmune or signaling process in PANDAS. The speed of recovery argues against a purely delayed antibody-mediated damage model and suggests a reversible immune-mediated trigger when addressed early.
Related Studies and Research
NSAIDs and PANDAS Flare Duration – Investigates whether NSAIDs shorten symptom flare duration.
Plasma Apheresis for Severe PANDAS Symptoms – Analyzes therapeutic plasma exchange in children with severe PANDAS.
PANDAS Antibiotics Prevention Study – Investigates how antibiotic use affects recurrence and prevention of PANDAS symptoms.
Podcast: Could Your Child’s Behavior Changes Be Cured with an Antibiotic? – A deep dive into the link between strep infections and dramatic neuropsychiatric symptoms.
Frequently Asked Questions
What behavior changes suggest PANDAS?
Sudden onset of severe OCD, separation anxiety, tics, or dramatic mood/attention shifts in a child is a red flag for PANDAS.
How fast do symptoms improve after treating the strep infection?
Most children improved within about 14 days of starting appropriate antibiotics. Some saw changes in as little as 5 to 6 days.
Does every strep infection cause PANDAS?
No. Only certain infections trigger PANDAS in susceptible children. A history of multiple prior strep exposures increased risk of a relapsing course.
Are these children strep carriers?
Evidence from negative cultures before and after episodes argues that they were not carriers. Each PANDAS flare matched a new infection.
Could something else mimic PANDAS?
This study did not identify other pathogens as causes. The strongest pattern seen was with group A strep, though other immune triggers have been hypothesized in broader literature.
Conclusion
This prospective primary care study strengthens the case that PANDAS is a distinct syndrome often triggered by group A strep and that early antibiotic treatment can produce fast and meaningful improvement. Clinicians and families should keep PANDAS on the differential for sudden behavioral changes in children and act quickly with testing and treatment when indicated. Early detection and intervention can prevent prolonged neuropsychiatric suffering.