Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a specific autoimmune response to group-A streptococcal (GAS) infections in children and adolescents with a sudden onset of neuropsychiatric disorders including obsessive-compulsive disorder (OCD) or tic-like symptoms. We present a case report of a 27-year-old male patient who had lasting improvement with plasmapheresis, rituximab, and ceftriaxone. Our patient first developed sudden psychosis and confusion after GAS infections at age 17. He had elevated anti-streptolysin O (ASO) titers, negative urine drug screen, no ETOH in blood, normal CBC, normal TSH, normal salicylate, normal acetaminophen, and a normal head CT. The tentative diagnosis of PANDAS was made, and the patient was thereafter treated with antipsychotics, antibiotics, tonsillectomy, and IVIG which resulted in remissions and relapses of his neuropsychiatric symptoms. Once he reached age 27, he received a trial of therapeutic plasma exchange (TPE), rituximab, and ceftriaxone. This eventually resulted in sustained benefit and minimal fluctuations of his clinical symptoms. Our report is noteworthy in three ways.One, he is a 27-year-old adult with PANDAS.Two, he improved after TPE, rituximab, and ceftriaxone. Our literature search yielded minimal data on the use of plasmapheresis for nonteenage adults with PANDAS. Three, he had unusual symptoms of PANDAS, as the typical OCD and/or tic-like symptoms were not observed.
Highlights
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) was first described by Swedo et al in the late 1990s and refers to a disease state characterized by the abrupt onset of neuropsychiatric symptoms
We present a 27-year-old-male with PANDAS who received therapeutic plasma exchange (TPE), rituximab, and ceftriaxone with significant improvement
The 5 diagnostic criteria proposed for PANDAS include (1) presence of obsessive-compulsive disorder (OCD) and/or a tic disorder, (2) prepubertal onset, (3) abrupt onset or exacerbation of symptoms with an episodic course, (4) temporal association of symptoms with group-A streptococcal (GAS) infection, and (5) association with neurological abnormalities including choreiform movements [4]
Summary
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) was first described by Swedo et al in the late 1990s and refers to a disease state characterized by the abrupt onset of neuropsychiatric symptoms. The most common are obsessive-compulsive disorder (OCD) and/or tics. Some researchers suggest that it may account for ≥10% of childhood-onset obsessive-compulsive disorder (OCD) and tic disorders [2]. Some strong evidence exists for the role of infection in triggering the symptoms of tics and OCD observed in these patients. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) are considered first-line therapy for acute-onset OCD spectrum and have been successful in patients with PANDAS [3]. Many patients undergo multiple treatment modalities that are often administered in conjunction with one another and with several modifications during their clinical course in an effort to achieve symptom improvement
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