PANS & PANDAS- from symptoms to diagnosis and treatment options.

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Heather Melena, MSN, APRN, PMHNP-BC

 

PANS stands for Pediatric Acute-onset Neuropsychiatric Syndrome and encompasses cases of strep induced neuropsychiatric presentations (PANDAS), as well as presentations brought on by other infections, toxins, or stress. To understand the mechanism in which this autoimmune response is triggered, we must understand how and what our immune system does. Our immune system (innate and adaptive) is responsible for several important roles in our bodies.  When our immune system wrongly identifies our own cells, which can resemble a pathogen’s cell, it attacks our own tissue and causes damage- otherwise known as molecular mimicry (Antoine, 2024). This is, very simply put, what evidence has shown to happen in autoimmunity. Autoimmune or autoinflammatory disease /illness (in PANS/PANDAS) is believed to be activated by exposure to several infectious pathogens that overthrow the immune system and/or generate abnormal reactions which then attacks neuronal cells, leading to inflammation and resulting symptoms (Pandas Physicians Network [PPN], 2024).

What are the hallmark signs and symptoms of PANS and PANDAS? Firstly, we see a very abrupt and severe onset of obsessive-compulsive disorder and/or severe restriction of food intake. With this initial onset, we usually see a rapid (which is unusual in most psychiatric conditions) onset of the following symptoms (PPN, 2024):

  • Severe separation and/or social anxiety (that is atypical for the person affected)
  • Severe mood lability
  • Irritability, aggression, or oppositional behaviors (that previously were not present)
  • Developmental regression
  • Significant and stark decline in school performance
  • Sensory integration dysfunction (to sounds, light, textures, smells
  • Tics or abnormal movements
  • Hypotonia, clumsiness, changes to fine motor skills
  • Enuresis (nighttime bedwetting)
  • Sleep disturbances (insomnia, night terrors)

It is important for people to understand that this is a very significant and drastic change that happens rapidly, if your child/adolescent is functioning normally, and then suddenly is struggling with these symptoms in a very severe manner that is out of character for their typical baseline, that is usually a tell-tale sign. If they have a history of psychiatric illness that ranges from mild to severe, and gets worse with an infection, that does not necessarily indicate PANS or PANDAS, though every case is unique. Approximately 88% of cases have a sudden onset, usually within 3 days (Antoine, 2024). Historically it was believed to have an onset from ages 3-11, though more recent evidence suggests that onset following puberty or even early adulthood, has been captured.

To diagnose, a very detailed and precise clinical picture must be obtained. We take a thorough history including past medical, surgical, and psychiatric history as well as understanding family history with an emphasis on autoimmune disorders. We complete a comprehensive physical exam and finally complete diagnostic studies to rule in/out other possible reasons for sudden and abrupt onset of symptoms as PANS & PANDAS is a diagnosis of exclusion. Lab studies including a complete blood count, complete metabolic panel, inflammatory markers, infectious disease, immune function, hormones, immunoglobins, nutritional deficiencies and autoantibodies are performed but is specific to the patient and their presentation.

How are PANS and PANDAS treated? Treatment is dependent on the severity of the case and at times can include a comprehensive treatment team to deliver care across several specialties including neurology, allergy/immunology, psychiatry, and more. More mild cases usually require antibiotics, steroids, anti-inflammatories, cognitive-behavioral therapy and very low doses of psychotropic medications (Neuroimmune Foundation, 2025). With more severe cases treatment can include IVIG, Plasmapheresis, longer courses of steroids, and other immunologic agents (Neuroimmune Foundation, 2025). It is important to help identify allergens, toxins, and environmental factors which could also be playing a role in the dysregulation of the immune system and continued inflammation.

References

Antoine, S. & Antoine, E. (2024). The comprehensive physicians’ guide to the management of PANS and PANDAS: An evidence-based approach to diagnosis, testing, and effective treatment. Forefront books.

Neuroimmune Foundation. (2025). What are PANS/PANDAS? https://neuroimmune.org/patient-and-family-resources/what-are-pans-pandas/

Pandas Physicians Network [PPN]. (2024). What is PANS/PANDAS? https://www.pandasppn.org/what-are-pans-pandas/

 Stanford Medicine Children’s Health. (2025). Diagnosis and Treatment for PANS and PANDAS. https://www.stanfordchildrens.org/en/services/pans-pandas/diagnosis-and-treatment.html