Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci


  • Also known as "PANDAS"
  • Controversial hypothesis that a subset of children with rapid onset of obsessive-compulsive disorder (OCD) or tic disorders caused by group A beta-hemolytic streptococcal (GABHS) infections[1]
  • Hypothesis is that antibodies against the cell wall of the streptococcal bacteria cross-react with neuronal brain tissue in the basal ganglia to cause the tics and OCD that characterize PANDAS

Clinical Features

  • Diagnostic criteria for PANDAS include[2]:
    • OCD and/or tic disorder
    • Pediatric onset (between three years and onset of puberty)
    • Abrupt onset and episodic course of symptoms
    • Temporal relation between GAS infection and onset and/or exacerbation
      • GAS infection is confirmed by:
        • Positive throat or skin culture or rapid antigen detection test for GAS at the beginning of a PANDAS exacerbation, or
        • Clinically significant rise in antistreptococcal antibody between the onset of symptoms and four to six weeks later
    • Neurologic abnormalities, such as motoric hyperactivity, choreiform movements, or tics during exacerbations

Differential Diagnosis


  • Evaluate for alternative etiologies of symptoms or precipitants of decompensation


  • Antistreptococcal therapy, (even if the episode of GAS was already treated given the failure rates for penicillin and amoxicillin therapy)
  • Azithromycin 12 mg/kg orally in one dose for five days (maximum dose 500 mg)
  • Treatment with azithromycin or clindamycin is advocated by some experts because of the possibility that GAS is intracellular[3]
  • Standard neuropsychiatric treatment for OCD and/or tic disorders


See Also

External Links


  1. Moretti G, Pasquini M, Mandarelli G, Tarsitani L, Biondi M (2008). "What every psychiatrist should know about PANDAS: a review". Clin Pract Epidemol Ment Health. 4 (1): 13.
  2. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998;155(2):264-71.
  3. Osterlund A, Engstrand L. An intracellular sanctuary for Streptococcus pyogenes in human tonsillar epithelium--studies of asymptomatic carriers and in vitro cultured biopsies. Acta Otolaryngol. 1997;117(6):883-8.