2017 Sec 1 Green Book

PANDAS: A systematic review of treatment options

Zachary Farhood, Adrian A. Ong, Christopher M. Discolo

Department of Otolaryngology

Head and Neck Surgery, Medical University of South Carolina, United States

a r t i c l e i n f o

Article history:

Received 26 April 2016

Received in revised form

9 August 2016

Accepted 10 August 2016

Available online 12 August 2016

Keywords:

Pediatric autoimmune neuropsychiatric

disorders associated with streptococcal

infections

Treatment

a b s t r a c t

Introduction:

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS)

is a rare but important condition for pediatric otolaryngologists to recognize. Several treatment options

exist including tonsillectomy, antibiotic treatment/prophylaxis, intravenous immunoglobulin (IVIG), and

psychiatric medications/therapy.

Methods:

A systematic review of the PubMed, EMBASE, and Scopus databases was performed searching

for articles that focused exclusively on the aforementioned treatment modalities in the PANDAS popu-

lation. Review articles, single patient case reports, and studies examining the natural history or diag-

nostic strategies were excluded.

Results:

Five articles regarding tonsillectomy treatments with level of evidence (LOE) 4 were found but

no clear bene

t could be determined. Three articles were selected involving the use of antibiotic therapy.

One prospective study and one double-blind randomized control trial (DB RCT) supported the use of

antibiotics but a separate DB RCT showed no bene

t. Two selected articles described the use of IVIG: one

unblinded RCT and one retrospective study. One prospective study on cognitive-behavioral therapy (CBT)

showed bene

t in PANDAS.

Conclusion:

There is a paucity of high-level studies regarding this rare disorder and no hard treatment

recommendations can be made. Tonsillectomy should only be performed in those who are surgical

candidates based on current published guidelines. Antibiotics are an option but provide uncertain

bene

t. CBT remains a low-risk option. Studies support the use of IVIG, however more investigation is

needed prior to widespread adoption of this treatment given its potential risks.

1. Introduction

Pediatric Autoimmune Neuropsychiatric Disorder Associated

with Streptococcus (PANDAS) is a rare pediatric disorder with

otolaryngic ties that was described by Swedo et al., in 1998 with

speci

c criteria (

Table 1

)

[1]

. The criteria continue to be re

ned but

the course of the disease involves tics and/or obsessions/compul-

sions that worsen in relation to acute infection caused by group A

hemolytic (GABHS) streptococcus. This is a waxing and waning

disorder with an incompletely understood pathophysiology.

Several treatment options have been proposed including surgery,

medical therapy, and cognitive behavioral treatment. The objective

of this study was to systematically review the literature for treat-

ment options of PANDAS.

2. Methods

Systematic reviews of published literature are deemed exempt

by our institutional review board. A systematic review of the

PubMed, EMBASE, and Scopus databases was performed in August

2015, searching for articles focusing exclusively on treatment mo-

dalities in the PANDAS population. The primary outcome was

improvement in symptoms. There were no date restrictions. The

speci

c search strategy is detailed in

Table 2

Articles in the English or Spanish language were included. Re-

view articles, single patient case reports, and studies examining the

natural history or diagnostic strategies were excluded. Two in-

dividuals (Z.F. and A.A.O) performed the search and analyzed each

article for appropriateness to include in the systematic review. The

This manuscript was presented at the 2015 Society for Ear, Nose, and Throat

Advancement in Children Meeting, December 4

6, 2015, San Antonio, TX.

Corresponding author. 135 Rutledge Ave, MSC 550, Charleston, SC 29425-5500,

United States.

E-mail address:

discolo@musc.edu

(C.M. Discolo).

Contents lists available at

ScienceDirect

International Journal of Pediatric Otorhinolaryngology

journal homepage:

http://www.ijporlonline.com/ http://dx.doi.org/10.1016/j.ijporl.2016.08.008

0165-5876/

International Journal of Pediatric Otorhinolaryngology 89 (2016) 149 e 153

Reprinted by permission of Int J Pediatr Otorhinolaryngol. 2016; 89:149-153.