Paediatric Acute-onset Neuropsychiatric Syndrome (PANDAS) misdiagnosed as autism: some implications

Credit: BBC Website 25 January 2019

The BBC website recently ran with an interesting story headed under the title: "Mother's appeal after boy diagnosed with autism when he just needed antibiotics." It was an interesting piece that drew attention once again to an increasingly important condition known as Paediatric Acute-onset Neuropsychiatric Syndrome (PANDAS) also called PANS.

Classically triggered by Streptococcal infections, PANDAS/PANS is typically characterised by quite an abrupt change in behaviour to include things like "clinically significant obsessions, compulsions and/or tics" alongside things like anxiety, sensory issues, aggression and a corresponding loss of academic abilities. Treatment is often multi-disciplinary; but in the most part intervention includes the use of various types of antibiotics clinically indicated to treat strep infections. This also follows a wider research-based thread suggesting that strep infections *might* have some important links to various neuropsychiatric conditions (see here).

The BBC piece specifically focused on how the young boy highlighted was "repeatedly diagnosed as having autism and severe anxiety" and how following a PANDAS diagnosis, and after just two days of antibiotic treatment, the mother of the young boy "felt like Jack was back." I'll also mention that the mum of Jack was herself a medic, a psychiatrist, and so was perhaps more attuned than most people about clinical diagnoses like autism and anxiety. It also emphasises how she kept on questioning...

Mention of the label autism in the BBC story got me thinking about quite a few things. Although still relatively sparse, there are some isolated reports in the peer-reviewed science literature observing that something like PANDAS/PANS can be "misdiagnosed as autism spectrum disorder" [1] in some circumstances. Such a notion complements some still emerging views that: (i) there may be many different routes to a diagnosis of autism (pertinent to the notion of 'the autisms'), (ii) autism is not universally an inborn genetic condition/state/diagnosis present from birth or early infancy, and (iii) autism for some people, is not necessarily a lifelong condition or label or state. Having discussed those views quite a bit on this blog (see here and see here and see here respectively) and noted some 'resistance' in some quarters to them, it is important that stories such as the one about Jack are continually highlighted. Not least because for him at least, his mother's determination and tenacity ultimately led to a new [accurate] diagnosis and subsequent treatment tailored to his particular circumstances. I daresay that other children (and even adults) who perhaps share Jack's clinical picture remain undiagnosed and untreated out there; something which represents a significant health inequality for them and their families. I might also add that the autism-anxiety diagnostic mix discussed in the BBC piece also complements the idea that the word 'comorbidity' may not be entirely accurate for the experience of [some] anxiety in the context of [some] autism (see here).

Jack's story begs the question: just how many people have been diagnosed with autism yet are 'suffering' with undiagnosed PANDAS/PANS? There's a research study there for someone brave enough there; alongside further study on whether elucidating the mechanisms of PANDAS/PANS when seemingly mimicking the signs and symptoms of autism & anxiety *could* be beneficial for at least some other parts of the wider autism spectrum...

Continue questioning and continue investigating seem to be the key lessons, as once again we are reminded that a diagnosis of autism should be a starting point and not 'the finishing line'.

----------

[1] Goncalves MVM. et al. Pediatric acute-onset neuropsychiatric syndrome (PANS) misdiagnosed as autism spectrum disorder. Immunol Lett. 2018 Nov;203:52-53.

----------

Group A Streptococcal infections and paediatric neuropsychiatric disorders: Taiwan style

There they go again. Taiwan and their 'big data' publishing, yet again, some rather interesting population-based research trends derived from data from the National Health Insurance Research Database (NHIRD).

This time around it is the paper by Han-Cheng Wang and colleagues [1] and the hypothesis to evaluate the "association between group A streptococcal (GAS) infections and the risks of developing tic disorders, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD)." For those in the know, the relationship between Strep infection and those neuropsychiatric labels brings us into the realm of PANDAS and PANS (and no, not the fluffy black-and-white kind of panda either).

Based on a not insignificant participant number - "2,596 patients and 25,960 controls" - researchers set about looking at under-18 year olds newly diagnosed with a GAS infection and their subsequent risk of receiving one or more of those neuropsychiatric labels.

Compared to controls, the incidence of neuropsychiatric disorder in the GAS group was higher (60.42 per 10,000 person-years vs. 49.32 per 10,000 person-years) particularly when it came to the presentation of a tic disorder. If said GAS infection was serious enough to put someone in hospital, the risk of neuropsychiatric disorder was even higher compared with than those who did not have a GAS infection. The authors conclude: "Our results confirmed an association between previous group A streptococcal infection and neuropsychiatric disorders."

Set within the growing research base suggesting that various infections can very much lead to behavioural outcomes (see here for another example) as well as physical ones, there is some interesting science still to be done on the hows and whys. Whether said infection meets us during the nine months that made us (see here) or some time after provides some intriguing insights on how timing and infection type might show differential effects for a person. The question of whether (a) we can prevent certain infections or (b) offset their primary effects via the use of agents affecting immune function or immune response perhaps represent some of the more important avenues for further investigations in this area.

----------

[1] Wang HC. et al. Group A Streptococcal Infections Are Associated With Increased Risk of Pediatric Neuropsychiatric Disorders: A Taiwanese Population-Based Cohort Study. J Clin Psychiatry. 2016 Jul;77(7):e848-54.

----------

Wang, H., Lau, C., Lin, C., Chang, A., & Kao, C. (2016). Group A Streptococcal Infections Are Associated With Increased Risk of Pediatric Neuropsychiatric Disorders The Journal of Clinical Psychiatry DOI: 10.4088/JCP.14m09728