Pediatric acute-onset neuropsychiatric syndrome (PANS) is a common diagnosis for children. PANS is an autoimmune condition caused by an infection that triggers an inflammation of the brain. This inflammation interferes with regular neurological activity. 

The inflammation may manifest with a wide range of symptoms. The child can begin to display motor tics, become aggressive or depressed, or start to have overall behavioral regression. PANS may also cause an acute onset of OCD, show signs of ADHD, or other neuropsychiatric presentations.

The immune system naturally produces antibodies to fight off infections. In a PANS patient, the body becomes confused and misdirects immune actions. The body’s antibodies mistakenly attack its normal, healthy tissue. More specifically, the body begins to disable the cell receptors and antigens in the movement and behavior portion of the brain, causing behavioral responses from the child. Internally, it creates an immune deficiency or dysfunction. 

The three most common PANS infections are:

• group A beta-hemolytic streptococcal (GABHS, aka “strep”)
• mycoplasma pneumoniae (aka “walking pneumonia”)
• coxsackie B virus

When these infections cause inflammation, molecular mimicry may also occur. This molecular mimicry is a neurological attack on the brain. Early on, this induces an “alternative fever response” by the brain’s cytokines, the cell communicators, and the immune system alert system.

Cytokines binding to cell receptors can interfere with or cause overstimulation of neurologic activity, which contributes to movement and neuropsychiatric disorders, OCD, and abnormal neurologic behavior. 

The most crucial factor in a PANS diagnosis is the sudden onset of behavioral symptoms. These are profound changes in the child that can occur within days or six months from the time of the infection. These changes occur because the antibiotics or treatment did not eradicate the cause.

Is PANS also PANDAS? 

PANDAS is still a recognized diagnosis. However, it is considered a subsection of PANS. 

PANS stands for Pediatric Autoimmune Neuropsychiatric Syndrome. It is a broader interpretation of PANDAS, Pediatric Autoimmune Neuropsychiatric Disorder Associated with the Strep bacteria. As you’ll notice, the primary difference in the name is the removal of “associated with the strep bacteria.” 

A medical paper written in 2012 by Dr. Susan Swedo expanded PANDAS’ definition to include more infections than group A beta-hemolytic streptococcal, or strep. She found that the other symptoms defining PANDAS also applied to other diseases, thus making PANDAS too specific.

The new PANS definition allows for a broader cause of PANDAS symptoms because strep does not need to be present. The clinical diagnosis criteria call for at least two of seven concurrent neuropsychiatric symptoms: anxiety, emotional breakdowns and/ or depression, aggressive or irritable behaviors, behavioral regression, sensory or motor abnormalities, and a biological symptom.

PANS vs. PANDAS

 PANS Criteria

• Abrupt onset of OCD or severely restricted food intake
• Concurrent presence of neuropsychiatric symptoms from at least 2 of 7 categories
• Symptoms not better explain by known neurologic or medical disorder.

PANDAS Criteria

• The onset of symptoms between age 3 and 11
• Acute onset
• Of motor/vocal tics and/or OCD 
• Temporally correlated with a Group A beta-hemolytic streptococcus (GABHS) infection 
• (Optional) Presence of choreiform signs: Irregular, spontaneous, rapid, random, or purposeless movement.

As we are learning more about autoimmune triggers associated with neuropsychiatric symptoms, the definition may need to be even broader. We now know that PANS not only affects children ages 3 to 11, but also infants, adolescents, and, adults. There is also Lyme induced PANS. The common denominator is now considered the inflammation of the brain caused by an infectious trigger.

Tonsils

Chronically infected tonsils are often a major contributing problem to inflammation of the brain and autoimmunity. The anatomic position of the adenoids and tonsils gives them an influential role as they are directly located in the lymph waterways leading out of the brain.

Most commonly, the tonsils are often infected or scarred up from strep, influenza, and mycoplasma pneumonia, creating a bottleneck that back-ups into the brain. Degenerated tonsils often house multiple bacterial and viral colonies and produce potent brain neurotoxins.

Be prepared that most Ear, Nose, and Throat (ENT) doctors often do not believe that tonsil infections are problematic and resist performing a tonsillectomy.