Submitted for publication 8/29/11
Reprint requests of the original article: Harvey Singer, MD, Rubenstein Child Health Bldg., 200 N Wolfe St., Ste 2158, Baltimore, MD 21287 email: firstname.lastname@example.org
All notes are taken directly from the article. The BLUE lettering is my personal remarks.
Introduction: Encountering a previously healthy child with acute, sudden onset of obsessive-compulsive behaviors, tics, abnormal movements, or other neuropsychiatric symptoms poses a dilemma for most physicians.... This report reviews each of the required clinical criteria for PANDAS. On the basis of inconclusive and conflicting scientific support for this diagnosis, a broader concept of childhood acute neuropsychiatric symptoms (CANS) is proposed....we mandate a comprehensive history and examination, consideration of a differential diagnosis, an active search for a specific etiology (infection or "other" cause) through appropriate laboratory testing, and treatment with the most appropriate therapy.
The Need to Move Beyond PANDAS: ....[T]he major diagnostic criteria for PANDAS has been its temporal association with GABHS. Nevertheless, there is strong evidence suggesting the absence of an important role for GABHS, a failure to apply published criteria, and a lack of scientific support for proposed therapies (papers cited saying there is "strong evidence against PANDAS" are primarily by the authors writing this paper: Singer, Gilbert and Kurlan).
Diagnosing a GABHS Infection: The authors describe how difficult and confusing it is to diagnosis strep with a positive swab and that ASO and D-Nase titer analysis is confusing.
Temporal Association of a GABHS Infection with PANDAS: In contrast to the initial event....recurrences of symptoms should occur within several weeks of a new infection. (This is a misinterpretation of the fact that symptoms usually do not entirely remit for kids with PANDAS....and any illness once the syndrome begins will create worsening of symptoms.) Recognizing these considerations, problematic results of laboratory testing and antibiotic treatment are reviewed....
Tourettes, Tics, OCD and GABHS Association: Studies have shown conflicting results and are not administered in enough detail. ....Several cross-sectional studies have reported higher ASO and DNASE-B titers in ....Tourettes...and (paraphrasing) several reports do NOT show a rise in ASO and D-Nase.
Two studies reviewed....US national health insurance samples have suggested that children with OCD, tic disorder, or TS were more likely to have had a streptococcal infection in the 3 months or year before the onset of neuropsychiatric symptoms. The risk was higher in children with multiple streptococcal infections within a 1 year period. (This is contrasted with two studies that looked at children who got STREP INFECTION. They were then followed to see if these were more likely to get OCD, TS, or tics disorders after the strep infection.....these people with strep infections did not get OCD, TS or tics.)
Is a GABHS Infection Associated with Recurrence of Tics, OCD or Both? Infections did....enhance the predictive power of psychosocial stress in predicting future tic and OC severity. (A long paragraph follows detailing a 2008 study by Kurlan and Kaplan where their samples of children have been heatedly disputed. In this study of 31 PANDAS children it was predicted they would have MORE strep infections....which is NOT what PANDAS is saying occurs.)
Does Antibiotic Treatment Suppress Symptoms and Does Prophylaxis Prevent Recurrences? Anecdotes have suggested that the treatment of "PANDAS" with unspecified does of a variety of antibiotics improves symptoms and in multiple cases immediately, at the initial treatment. This finding, however, has never been the subject of a clinical trial. The biological explanation for the immediate response to antibiotics, if correct, is unclear.....(Regarding prophylaxis studies are too small and results unclear though few infections and neuropsychiatric exacerbations occurred). Thus, as of this time, the use of antibiotics for secondary prevention of PANDAS appears unwarranted.
Concerns about PANDAS Criteria: The authors describe in detail that age limit should be removed; tics are common in 20-30% of children; and why look at OCD symptoms only as a critieria-other neuropsychiatric symptoms should be considered. They further say that sudden onset is not defined well and "saw-tooth pattern" is unclear in many reports.
Presence of Neurologic/Behavioral Abnormalities during Exacerbations: Potential difficulties separating "choreiform" movements from chorea has led to suggestions that some cases might have had Sydenham Chorea. Additional study is required to clarify .... co-morbid symptoms [for example] emotional lability, intense anxiety, cognitive-deficits, oppositional behaviors or motoric hyperactivity.
CANS: Having identified significant limitation to the PANDAS hypothesis, it is suggested that this diagnosis be eliminated....Our suggested approach adopts a more encompassing concept of acute fulminant neuropsychiatric symptoms, but requires an active search for a specific etiology. The proposed CANS classification does not require association with a specific organism, limitation of symptoms to tics or OCD, a specific age range, or recurrence of symptoms. It does, however, require an acute dramatic onset, a comprehensive history and examination, and diagnostic evaluation.
DIFFERENTIAL DIAGNOSES: It is required to check the child for any of the below listed diagnoses:
TABLE includes 36 differential diagnoses: Infection, Encephalitis, Metabolic/Endocrine Issues, Drug Induced, Toxic Ingestions, Trauma, Vascular, Autoimmune, Seizures, Psychogenic. No mention of strep or mycoplasma, lyme or any other typical PANDAS onset illness is mentioned.
TABLE OF WORKUPS: 14+ blood tests, Urine Samples, Lumbar Puncture, Brain Imaging, EEG.
Idiotpathic CANS Where the above tests are inconclusive for CANS, this is idiopathic. An ongoing uncertainty is how to classify an categorize patients with CANS who, after comprehensive examination lacks a specific etiologic diagnosis. At this time....it is unknown if this group will have a laboratory finding.
Therapeutic Approach: Recommended treatments for OCD are SSRIs; for ADHD, stimulants, for chorea and tics..... dopamine antagonists. Because the existence of PANDAS condition remains controversial, the routine use of antibiotics or immune-modifying therapies (corticosteroids, IVIG, plasma exchange) is not recommended.
Future Research: It is strongly recommended that a national centralized registry be established for the collection of standardized and longitudinal information on this cohort... this will permit the performance of randomized, controlled, clinical trials of rational therapy.
Here is a pdf version of my summary.