Does plasma apheresis help children with severe PANDAS?
Yes, in this case series, though it had no comparison group. Parents reported an average 65% improvement in symptoms 6 months after treatment and 78% at longer follow-up, and 7 of 35 children were in complete remission. This was a retrospective review of 35 severely ill children and teens treated at Georgetown University Hospital.
Dr. Kumar’s Take:
This case series from Georgetown University offers encouraging evidence that therapeutic plasma apheresis (TPA) can bring life-changing improvements for children suffering from severe PANDAS. Most had already failed standard therapies, yet parents reported an average 65% improvement at 6 months and 78% improvement at long-term follow-up. TPA seems especially helpful when symptoms are extreme, such as aggression, suicidality, or dangerous food refusal. It’s not a first-line treatment, but it can be a critical option when all else fails.
Key Takeaways:
✔ Parents reported overall PANDAS symptoms improved by 65% at 6 months and 78% at long-term follow-up after TPA
✔ Improvements seen in OCD, anxiety, tics, rage, sleep issues, eating disorders, and more
✔ Even children with years of chronic illness showed major improvement
✔ Side effects were rare and minor, mainly related to central line care
✔ No symptom worsening was seen in any patient after TPA
Actionable tip:
For children with severe or treatment-resistant PANDAS, especially those with suicidal thoughts, violent behavior, or eating refusal, TPA may be worth discussing with a specialist. When used with infection prevention and ongoing psychiatric care, it can be a powerful part of a comprehensive plan.
What This Study Looked At:
Researchers reviewed the outcomes of 35 children and adolescents with severe PANDAS who received therapeutic plasma apheresis (TPA) at Georgetown University Hospital between 2009 and 2013. All patients met diagnostic criteria for PANDAS and had severe symptoms. All had taken antibiotics without relief. Some had also had little or no response to oral steroids (5 children, 14%) or IVIG (17 children, 48%).
How Plasma Apheresis Works in PANDAS:
PANDAS is thought to be caused by immune system antibodies that mistakenly attack the brain after a strep infection. TPA is a blood-cleaning process that filters the plasma. The authors note that how it helps is not known, in PANDAS or any other condition. It has been used in other autoimmune conditions like Sydenham chorea with success.
Study Design:
- Patients: 35 children (23 boys, 12 girls), average age 11.5
- Treatment: 3 plasma exchange procedures (1.5x blood volume each) over 3 to 5 days
- Follow-Up: Symptom improvement measured at 6 months and long-term (up to 5 years)
- Setting: Georgetown University Hospital
Results:
- Average symptom improvement:
- 65% at 6 months
- 78% at long-term follow-up
- Complete remission in 7 children
- Improvement seen in:
- OCD (97% → 23%)
- Tics (63% → 17%)
- Aggression (69% → 6%)
- Suicidal thoughts (23% → 0%)
- Eating disorders (20% → 3%)
- No correlation between length of illness and how much a child improved
- Adverse events: Two mild bleeding episodes at central line sites, resolved easily
When to Consider TPA for PANDAS
According to the authors, TPA should be reserved for:
- Severe cases with risk of self-harm or harm to others
- Children with major eating restrictions or malnutrition
- Patients who remain severely ill after less invasive treatments such as antibiotics and possibly oral steroids
Real-World Examples from the Study:
Three detailed cases showed:
- Complete recovery from OCD, aggression, or food refusal
- One boy relapsed after a new infection and needed a second course of TPA
- All three improved after TPA, though some earlier treatments such as steroids and IVIG had not helped
- One girl’s sister also developed PANDAS and responded to the same protocol
Related Studies and Research
PANS and Corticosteroids: A Study Review: Reviews outcomes of corticosteroid use during PANS flares.
NSAIDs and PANDAS Flare Duration: Investigates whether NSAIDs shorten symptom flare duration.
Azithromycin for PANS-Related OCD: Evaluates the role of azithromycin in treating obsessive-compulsive 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
Is TPA safe for kids with PANDAS?
Yes. In this study of 35 children, there were no serious side effects. Minor issues included bleeding at the catheter site, which resolved with simple care.
Does it work better for new or chronic symptoms?
Surprisingly, it worked equally well for children who had been sick for years and those who had recent symptoms.
What symptoms improved the most?
OCD, anxiety, aggression, eating problems, tics, and even suicidal thoughts, all showed major improvement after TPA.
Is plasma apheresis a first-line treatment?
No. The authors recommend less invasive treatments, such as antibiotics and possibly oral steroids, first. TPA is for severe, treatment-resistant cases, with two exceptions: life-threatening suicidality or aggression, and severe food or fluid restriction.
Conclusion
Therapeutic plasma apheresis may offer hope for children with the most severe, hard-to-treat forms of PANDAS. When symptoms like OCD, rage, or eating refusal threaten a child’s safety and quality of life, TPA could be a powerful part of a broader treatment plan. The improvements were not only dramatic, but lasting, and the treatment was remarkably safe.
