We have known for many years that the bacteria, beta-hemolytic group A Streptococcus, causes sore throats with fever and swollen lymph nodes in the neck. We also know that there are rare and severe complications that can occur when this infection is left untreated. These are Acute Rheumatic Fever (inflammation of the heart, joints, skin and nervous system), and Acute Glomerulonephritis (a kidney problem). Milder forms of arthritis are also often traced to Strep. These conditions arise when the child's immune system produces excess amounts of antibody to fight the strep. This excess antibody can mistakenly attack the heart, brain, joint lining, or kidneys, causing disease.
The fear of these complications has led to the development of throat cultures and fast tests that can be performed in the office or lab. When Group A Beta strep is identified antibiotics are prescribed.
It has long been noted that about 50% of cases of rheumatic fever had no history of sore throat or heat before the attack. It is assumed that not all strep infections cause an identifiable illness, and not all are in the throat. Sinusitis, ear infections, and genital infections can be caused by Group A strep. These often go undiagnosed and untreated because they do not usually cause fever and systemic illness.
In 1998 Dr. S. Swedo from the National Institutes of Health described another pediatric problem caused by strep- Obsessive-Compulsive Disorder. She described a group of patients who developed psychiatric symptoms during or after a strep infection. These children were all before puberty and did not respond to the usual psychiatric medications. They all had extremely elevated levels of the anti strep antibody, DNASE B. Some of them improved dramatically after treatment with antibiotics.
Since that time, other neuropsychiatric disorders in young children, including tics, Tourettes, anxiety disorders, and significant behavior changes have been attributed to strep infections. The syndrome was labeled PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep). Extensive studies are going on now in major medical centers to study PANDAS. They are trying to determine if the patients do improve on antibiotics and whether they need long term prophylactic doses to prevent relapse. It will be about two years before this information will be published. Meanwhile, many pediatricians are considering strep when one of their young patients suddenly develops a neuropsychiatric disorder.
The symptoms can be varied in different children. The most obvious one is tics, which are involuntary facial and body movements such as eye-rolling, grimacing, or tapping hands or feet. Other symptoms include involuntary noises such as snorting squeaking or even yelling. Some of the children develop strange habits such as running to the bathroom every few minutes in fear of wetting themselves. Some have more classsic obsessive thoughts such as fear of germs or guilt over trivial transgressions and compulsive behaviors, such as hand washing or even excessive praying. Sometimes the child will have a sudden change of personality or behavior such as a naturally even-tempered child becoming impulsive, oppositional, or obnoxious.
Some of the children develop severe anxieties that interfere with normal function, such as fear of leaving home. Many of these children experience joint pains or headaches, along with the change in behavior.
When a parent complains of a dramatic change in their child, it is now known that this child needs a throat culture and a blood test for the DNASE B antibody. If either test is abnormal, the diagnosis of PANDAS should be considered. The treatment for these children should be a course of antibiotics. Which one is not well understood. Many doctors are using Amoxicillin or Keflex. However, there is some evidence that Zythromax can result in a quicker and more dramatic return to normal behavior.
The pediatric psychiatric community is not yet in tune with this diagnosis. Any prepubertal child who experiences deterioration in his or her mental function should be tested for DNASE B antibody and the throat cultured. If either of these tests is abnormal, a course of antibiotics (in my experience, Zythromax) should be attempted before a psychiatric referral is made since it often results in a cure.
PANDAS is still a new and somewhat unproven concept. The fact is, however, that I have seen many examples that seem to fit the diagnosis and respond well to this "unusual" treatment.
The problem can recur with subsequent strep infections. When the "PANDAS" behavior starts to become evident again, another treatment with antibiotics usually resolves the issue. Some doctors feel that after a recurrence a 6-12 month course of low dose Amoxil two times a day should be given to prevent strep infections.
Even though we, as pediatricians, are trying hard not to use antibiotics unnecessarily this is one instance where we must consider treatment as critically important. Although most kids with tics and even childhood OCD improve with time, the PANDAS symptoms can, if left untreated, become permanent. This is, admittedly, a strange new idea, but for the parents of a child with PANDAS, the relief experienced when their child returns to normal is indescribable.
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