Parents and caregivers in the autism community often express concern about neuropsychiatric disorders like PANS, PANDAS, CANS, and PITANDS. Diagnosing these conditions can be challenging, especially because their symptoms often overlap with those of autism. However, one critical factor that sets these disorders apart is the abrupt onset of symptoms, as opposed to the gradual progression seen in autism.
In this blog, we’ll explore these disorders in detail, shedding light on their symptoms, diagnosis, and treatment options, both conventional and holistic.
What is PANS?
PANS stands for Pediatric Acute-onset Neuropsychiatric Syndrome—a clinical diagnosis characterized by a sudden onset of severe neuropsychiatric symptoms in children. Since PANS is a diagnosis of exclusion, a thorough medical history and physical examination are essential to rule out other conditions.
Key Symptoms of PANS
To confirm a diagnosis, a child must exhibit:
Obsessive-Compulsive Disorder (OCD) and/or restrictive food intake
Plus, at least two or more of the following symptoms:
Anxiety
Emotional instability (lability)
Depression
Irritability or aggression
Severe oppositional behavior
Behavioral or developmental regression
Decline in school performance (e.g., handwriting, math skills)
Sensory abnormalities
Sleep disturbances
Enuresis (bedwetting) or frequent urination
Motor or vocal tics
Common OCD Symptoms in PANS
Children with PANS often display OCD behaviors such as:
Intrusive thoughts or disturbing images
Obsessions with cleanliness or germs
Repeated compulsive actions (e.g., handwashing)
A rigid need for sameness or routines
Compulsions to confess, seek reassurance, or ask repetitive questions
Fear of self-harm or harming others
Repetitive speech, counting, or arranging objects
Hoarding behaviors
Religious or moral obsessions
Food-related rituals
A sudden onset of symptoms is critical for diagnosing PANS, though identifying a specific trigger is not required. There is no age restriction, and early recognition of the condition is key to ensuring proper care and management.
Understanding PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
PANDAS refers to a condition in which a Group A Streptococcal (GAS) infection triggers the sudden onset of Obsessive-Compulsive Disorder (OCD) and/or tic disorders in children. This autoimmune response results in neuropsychiatric symptoms that can be acute and episodic.
Diagnostic Guidelines for PANDAS
The diagnosis of PANDAS is based on the following criteria:
Presence of OCD and/or tics
Onset of symptoms between ages 3 and puberty
Sudden, acute onset with a relapsing-remitting pattern
Association with a Group A Streptococcal (GAS) infection
Co-occurrence of neurological abnormalities
While comorbid neuropsychiatric symptoms are not required for diagnosis, they are commonly observed.
Complications Linked to Group A Streptococcal Infections
GAS infections (e.g., tonsillitis, sinusitis, skin infections) can lead to severe complications due to:
Direct infection or release of exotoxins such as:
Streptolysin, DNase, and streptokinase
Resulting conditions:
Scarlet fever
Toxic shock syndrome
Necrotizing fasciitis
Puerperal sepsis
Immune-mediated responses causing:
Rheumatic fever (affecting joints, heart, and brain)
Post-streptococcal glomerulonephritis
Sydenham chorea
PANDAS
Related Terms
CANS (Childhood Acute Neuropsychiatric Symptoms)
A broader category encompassing PANS and PANDAS, it describes acute neuropsychiatric symptoms in children without a specific infectious or autoimmune cause.
PITANDS (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders)
This term, now outdated, previously referred to sudden-onset OCD in children linked to infections other than GAS.
Laboratory Testing for PANS and PANDAS
While PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) is a clinical diagnosis with no definitive lab test, laboratory evaluations play a crucial role in guiding treatment and differentiating between PANS and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections).
Commonly Ordered Laboratory Tests
Healthcare providers may order the following tests to evaluate potential underlying causes and contributing factors:
Throat or perianal culture (to detect Group A Streptococcal infection)
ANA titer (to assess for autoimmune disorders)
ASO titer and Anti-DNase B antibody (to detect recent streptococcal infections)
Streptozyme test
Lyme Western Blot (IgG and IgM) in Lyme-endemic regions
Mycoplasma pneumoniae antibodies (IgM, IgG)
Comprehensive Metabolic Panel (CMP) including ammonia levels
Quantitative immunoglobulins (IgG, IgA, IgE, IgM)
Anemia panel
Inflammatory markers like ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein)
Complement levels (C3 and C4)
Thyroid panel (including thyroid antibodies)
Urinalysis
Key Insights from Testing
Negative titers or strep cultures do not rule out PANS.
Positive lab values alone do not confirm PANS or PANDAS but provide supportive evidence.
Presence of strep infection is a critical factor for distinguishing PANDAS from PANS.
Diagnostic Context for PANDAS, PANS, CANS, and PITANDs
Reference: Diagnostic Approach to Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections PANDAS written by Adriana Prato, Mariangela Gulisano, Miriam Scerbo, Rita Barone, Carmelo M. Vicario, and Renata Rizzo
Understanding the nuanced differences in diagnostic criteria for PANS, PANDAS, CANS (Childhood Acute Neuropsychiatric Symptoms), and PITANDs ensures a tailored approach to care.
Treatment Options for PANS PANDAS CANS & PITANDS
No generally-accepted treatment regimen
Conventional Treatment PANS, PANDAS, CANS, & PITANDS
Antibiotics to treat infections such as group A Streptococcus, sinusitis, otitis media, Mycoplasma pneumoniae, etc..
Penicillin, Amoxicillin-Clavulanate, Azithromycin, Clarithromycin, Cephalexin, Cefadroxil, Cefdinir, Clindamycin, etc.
NSAIDS
Inflammation may play a role in triggering and/or exacerbating PANS/PANDAS symptoms. Based on the research reviewed, both prophylactic and early NSAID treatment were associated with a significantly shorter flare duration than no NSAID use.
The doses used in the study are listed below:
Ibuprofen 10 mg/kg every 6–8 hours (maximum: 600 mg/dose)
Naproxen 10 mg/kg every 12 hours (maximum: 500 mg/dose)
Sulindac was dosed at 2–4 mg/kg every 12 hours (maximum: 6 mg/kg/day, adult maximum dose = 400 mg/day divided twice a day).
Celecoxib was dosed at 50–100 mg twice a day.
Patients on chronic NSAIDS should be monitored for symptoms such as headaches, allergic reactions, bruising, gastrointestinal side effects. Lab Testing such as Comprehensive Metabolic Profile, Complete Blood Count, and Urinalysis is recommended every 3-6 months for patients on chronic NSAIDS.
Immune Modulation Therapy/Immunomodulatory
Methylprednisolone 30mg/kg/day for 3 days; repeat monthly (Response to steroids assists with diagnosis).
IVIG; repeat monthly
Rituximab; two doses initially, repeat in 6 months if needed
Plasmaphoresis
Cyclophosphamide
Mycophenylate mofetil
Other interventions/treatment
Exercise
Psychotherapy
Cognitive Behavioral Therapy
SSRIs
Holistic Treatment
Based on the research, inflammation is involved in the presentation of most patients with neuropsychiatric disorders such as PANS, PANDAS. Anti-inflammatory medications seem to lessen or shorten the course of symptoms in patients treated with PANS/PANDAS. There are many supplements that can be used to treat inflammation and supplements that can be very helpful in symptomatic management of symptoms in these disorders. Most of the supplements, herbs, and essential oils with some research are listed below, even though further research is needed. The gut microbiome also plays an important role in immune function and inflammation. This should also be addressed in the treatment protocol. In the holistic management of PANS PANDAS we focus on the body as a whole and not just on the diagnosis. Therefore, it is helpful to treat other problems that affect the body when treating PAND PANDAS. So testing and treating vitamin deficiencies, mineral deficiencies, heavy metals overload, and addressing other infections, such as candida, clostridia, parasites, is also important.
Natural Antimicrobials
Probiotics and Prebiotics including Saccharomyces Boulardii
Antimicrobial herbs for strep including:
Usnea
Taiga (Pine needle extract)
Berberine (Goldenseal)
Neem
Oregano Oil
Colloidal Silver
Cordyceps
Antimicrobials herbs for mycoplasma:
Berberine/Goldenseal
Thyme/Oregano
Colloidal Silver
Houttuynia
Antimicrobials herbs for viruses:
L-Lysine
Monolaurin
Elderberry
Olive Leaf
Glycyrrhiza (Licorice)
Lemon Balm
Interventions or treatment symptoms associated with PANDAS and PANS, such as anxiety, OCD, and tics:
Supplements:
5-HTP
GABA
L-Theanine
Inositol
Magnesium
L-MTHF
Ashwagandha (Withania somnifera)
Lemon Balm
Motherwort
Passionflower (Passiflora incarnata)
Saffron
Mimosa Bark
Hemp oil
N acetyl Cysteine/Glutathione
Silexan
Kava kava
Ginkgo biloba
Aloe vera
Rosemary (Rosmarinus officinalis)
Omega-3 Fatty Acids
Antimicrobial Essential oils:
Lamiaceae family (Lavender, Thyme, and Peppermint)
Cinnamon
Clove
Eucalyptus
Sage
Tea Tree
Dietary Invention
In any medical condition, diet is very important, and getting nutrients from the diet is crucial as these nutrients help the body to heal. In most of these inflammatory disorders, reducing inflammation in the diet is key in the healing process. It is important to eliminate all highly-processed foods. It is recommended to do USDA-Certified Organic foods, homecooked food is preferred. Most patients would benefit from an anti-inflammatory diet, reducing sugars in the diet. Focus on eating foods rich in healthy fats and fiber and flavonoids.
One of the most well-known and studied flavonoids is kaempferol and it is an antioxidant, anti-inflammatory, anti-cancer, cardioprotective, neuroprotective, anti-allergic, antibacterial, antifungal, and antiprotozoal. It can be found in a wide variety of herbs and plant families as listed below:
Tea/green tea
Beans
Broccoli
Apples
Strawberries
Grapes
Tomatoes
Potatoes
Onions
Broccoli
Brussels sprouts
Squash
Cucumbers
Lettuce
Green beans
Peaches
Blackberries
Raspberries
Spinach
Conclusion
Addressing PANS, PANDAS, CANS, and PITANDS requires a multifaceted approach, combining medical treatments with lifestyle and dietary modifications. Early identification and intervention are crucial for better outcomes. Whether through antibiotics, immune therapy, or natural remedies, the goal is to restore balance and support the child’s overall well-being.
By combining conventional and holistic treatments, patients can experience significant relief from PANS, PANDAS, and related conditions. Consult with our healthcare professionals to develop a personalized care plan.
References
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