Clinical Evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the 2013 PANS Consensus Conference

By Chang, Kiki; Frankovich, Jennifer et al. | Journal of Child and Adolescent Psychopharmacology, February 2015 | Go to article overview

Clinical Evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the 2013 PANS Consensus Conference


Chang, Kiki, Frankovich, Jennifer, Cooperstock, Michael, Cunningham, Madeleine W., Latimer, M. Elizabeth, Murphy, Tanya K., Pasternack, Mark, Thienemann, Margo, Williams, Kyle, Walter, Jolan, Swedo, Susan E., Journal of Child and Adolescent Psychopharmacology


[Author Affiliation]

Kiki Chang. 1 Professor of Psychiatry, Director of the Pediatric Bipolar Disorders Program, Stanford University School of Medicine, Stanford, CA.

Jennifer Frankovich. 2 Clinical Assistant Professor of Pediatrics-Rheumatology, Stanford University School of Medicine, Stanford, California.

Michael Cooperstock. 3 Chief, Division of Infectious Diseases and Rheumatology, University of Missouri School of Medicine, Columbia, Missouri.

Madeleine W. Cunningham. 4 Professor of Microbiology and Immunology, University of Oklahoma College of Medicine, Norman, Oklahoma.

M. Elizabeth Latimer. 5 Pediatric Neurologist, Latimer Neurology Center, Bethesda, Maryland.

Tanya K. Murphy. 6 Director and Professor of Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida, St Petersburg, Florida.

Mark Pasternack. 7 Unit Chief of Pediatric Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts.

Margo Thienemann. 8 Associate Professor on the Adjunct Clinical Faculty, Stanford University School of Medicine, Stanford, California.

Kyle Williams. 9 Director of the Behavior and Immunology Clinic in the OCD and Related Disorders Program, Massachusetts General Hospital, Boston, Massachusetts.

Jolan Walter. 10 Director, Pediatric Immunodeficiency Program, Massachusetts General Hospital, Boston, Massachusetts.

Susan E. Swedo. 11 Chief, Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health ( NIMH) , Rockville, Maryland.

* Co-first authors.

© The Author(s) 2015; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons Attribution Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

Address correspondence to: Kiki D. Chang, MD, Stanford University School of Medicine, Division of Child and Adolescent Psychiatry, 401 Quarry Road, Stanford, CA 94305-5540, E-mail: kchang88@stanford.edu

Background

In the 1980s, investigators at the National Institutes of Health (NIH) noted a subset of children with obsessive-compulsive disorder (OCD) who had a sudden onset of their psychiatric symptoms, typically following infection with a variety of agents, including Streptococcus pyogenes, varicella, and Mycoplasma pneumoniae. These were termed pediatric infection triggered autoimmune neuropsychiatric disorders (PITANDS) (Allen et al. 1995). The investigators chose to focus on the subset of cases triggered by infections with group A Streptococcus (GAS) because of parallels between acute-onset OCD and the prodromal period of Sydenham chorea (SC), suggesting that acute-onset OCD might be a forme fruste of SC (Swedo et al. 1989; Swedo 1994; Swedo et al. 1994).

Systematic clinical investigations of SC and OCD led to discovery of a subgroup of OCD patients whose symptoms were triggered by GAS infections and labeled "pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections" (PANDAS) (Swedo et al. 1998). The PANDAS subgroup is defined by an acute prepubertal onset of tics or OCD symptoms, association with GAS infection, and specific neuropsychiatric symptoms (Swedo et al. 1998, 2004; Murphy et al. 2012).

The requirement that GAS infections be associated with symptom onset/exacerbations proved difficult to operationalize, because of the prevalence of GAS infections in grade-school aged children, and the asymptomatic nature of rheumatogenic GAS organisms (Garvey et al. 1998); this resulted in both misdiagnoses and missed diagnoses of PANDAS (Gabbay et al. 2008). Additional problems were encountered in patients with tic disorders because the PANDAS subgroup is distinguished by an "abrupt onset and episodic course," but tics are frequently described as having an acute ("off/on") onset and a waxing/waning course (Leckman et al. …

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