![Show Menu](styles/mobile-menu.png)
![Page Background](./../common/page-substrates/page0082.jpg)
tonsillectomy was not shown to be an effective treatment modality
for PANDAS except in small anecdotal settings, and those who did
improve were also subject to other treatments including neuro-
psychiatric medications and/or antibiotics, confounding the true
results of tonsillectomy. Therefore, it is suggested that practitioners
continue to offer tonsillectomy per the current American Academy
of Otolaryngology-Head
&
Neck Surgery guidelines
[9]
.
Antibiotic therapy has two strategies: prophylaxis and treat-
ment. By preventing infection or rapidly treating with antibiotics,
one would expect a reduction in symptom severity. In this sys-
tematic review, prophylaxis did not appear bene
fi
cial but acute
episodes did seem to resolve when treated with antibiotics. Based
on this we can conclude that antibiotic therapy remains an option
in the management of PANDAS, but ef
fi
cacy is uncertain.
Due to the proposed autoimmune component of PANDAS, IVIG
has been considered as a possible treatment option. It has previ-
ously been studied in patients with rheumatic fever and was sug-
gested to improve symptoms associated with Sydenham's chorea
[24,25]
. Although there may be bene
fi
t from IVIG for exacerba-
tions and recurrences, it is not a benign treatment and the potential
risks and complications should be weighed when deciding to
employ it. It is worth noting that while adverse events were
frequent in these studies, all were considered mild. Steroids are
unlikely to be used in this population as they may worsen the
neuropsychiatric symptoms
[14,26]
.
CBT confronts PANDAS from a psychiatric standpoint and due to
the minimal risk involved in receiving therapy, it can be recom-
mended for management of symptoms. Unlike traditional OCD, the
symptoms of PANDAS have an abrupt onset and resolution which
manifest at an earlier age
[27]
. Only one case report utilizing SSRIs
was identi
fi
ed, but not included in this systematic review
[28]
. This
treatment caused behavioral activation in the patient consisting of
mood instability and suicidality.
A substantial obstacle in evaluating treatment modalities is that
most have received multiple treatments, leaving interpretation
susceptible to confounding factors. Furthermore, the pathophysi-
ology is still poorly de
fi
ned/understood. Finally, this is a rare disease
with an uncertain prevalence
[29]
. Antibiotics, SSRIs, and IVIG may
continue to be studied as there is currently a Phase 2 clinical trial
registered on
clinicaltrials.gov[30]
. In spite of these limitations, the
current study summarizes the evidence for treatment strategies in
the PANDAS population and can serve as a reference for otolaryn-
gologists who may be less familiar with the disease.
5. Conclusion
Assessing treatment strategies for PANDAS remains dif
fi
cult, as
it is a rare disease with few published high quality studies. Many of
these studies are retrospective in nature and consist of small pop-
ulations. Furthermore, patients often undergo multiple treatment
modalities, leaving room for confounding. Adenotonsillectomy
does not seem to clearly bene
fi
t this patient population. Antibiotics
may prove to be useful in preventing or treating infections and
therefore neuropsychiatric exacerbation, but there is limited evi-
dence to recommend it. Though IVIG proved to be effective in
certain patient populations, it is not without serious risk and should
be reserved for the immunocompromised or most severe cases.
Finally, traditional psychiatric therapy for PANDAS may be effective
and is of minimal risk to the patient.
Funding
None.
Con
fl
icts of interest
None.
References
[1]
S.E. Swedo, H.L. Leonard, M. Garvey, et al., Pediatric autoimmune neuropsy- chiatric disorders associated with streptococcal infections: clinical description of the fi rst 50 cases, Am. J. Psychiatry 155 (2) (1998) 264 e 271.
[2]
J. Howick, I. Chalmers, P. Glasziou, et al., The 2011 Oxford CEBM Levels of Evidence, CEBM, Oxford, UK, 2011.
[3]
L.J. Orvidas, M.J. Slattery, Pediatric autoimmune neuropsychiatric disorders and streptococcal infections: role of otolaryngologist, Laryngoscope 111 (9) (2001) 1515 e 1519 .[4]
C. Heubi, S.R. Shott, PANDAS: pediatric autoimmune neuropsychiatric disor- ders associated with streptococcal infections e an uncommon, but important indication for tonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 67 (8) (2003) 837 e 840 .[5]
T.K. Murphy, E.A. Storch, A.B. Lewin, P.J. Edge, W.K. Goodman, Clinical factors associated with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, J. Pediatr. 160 (2) (2012) 314 e 319 .[6]
T.K. Murphy, A.B. Lewin, E.C. Parker-Athill, E.A. Storch, P.J. Mutch, Tonsillec- tomies and adenoidectomies do not prevent the onset of pediatric autoim- mune neuropsychiatric disorder associated with group A streptococcus, Pediatr. Infect. Dis. J. 32 (8) (2013) 834 e 838 .[7]
P. Pavone, V. Rapisarda, A. Serra, et al., Pediatric autoimmune neuropsychiatric disorder associated with group a streptococcal infection: the role of surgical treatment, Int. J. Immunopathol. Pharmacol. 27 (3) (2014) 371 e 378 .[8]
D. Demesh, J.M. Virbalas, J.P. Bent, The role of tonsillectomy in the treatment of pediatric autoimmune neuropsychiatric disorders associated with strep- tococcal infections (PANDAS), JAMA Otolaryngol. Head Neck Surg. 141 (3) (2015) 272 e 275 .[9]
R.F. Baugh, S.M. Archer, R.B. Mitchell, et al., Clinical practice guideline: ton- sillectomy in children, Otolaryngol. Head Neck Surg. 144 (1 Suppl) (2011) S1 e S30 .[10]
M.A. Garvey, S.J. Perlmutter, A.J. Allen, et al., A pilot study of penicillin pro- phylaxis for neuropsychiatric exacerbations triggered by streptococcal in- fections, Biol. Psychiatry 45 (12) (1999) 1564 e 1571 .[11]
M.L. Murphy, M.E. Pichichero, Prospective identi fi cation and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS), Arch. Pediatr. Adolesc. Med. 156 (4) (2002) 356 e 361 .[12]
L.A. Snider, L. Lougee, M. Slattery, P. Grant, S.E. Swedo, Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disor- ders, Biol. Psychiatry 57 (7) (2005) 788 e 792.
[13]
M.J. Redondo-Granado, P. Garcia-Saseta, I. Vizcaino-Lopez, R. Palencia-Luaces, Successful treatment with benzathine penicillin of two patients suspected of suffering from PANDAS, Rev. Neurol. 54 (2) (2012) 125 e 127 .[14]
S.J. Perlmutter, S.F. Leitman, M.A. Garvey, et al., Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood, Lancet 354 (9185) (1999) 1153 e 1158 .[15]
M. Kovacevic, P. Grant, S.E. Swedo, Use of intravenous immunoglobulin in the treatment of twelve youths with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, J. Child. Adolesc. Psycho- pharmacol. 25 (1) (2015) 65 e 69.
[16]
E.A. Storch, T.K. Murphy, G.R. Geffken, et al., Cognitive-behavioral therapy for PANDAS-related obsessive-compulsive disorder: fi ndings from a preliminary waitlist controlled open trial, J. Am. Acad. Child. Adolesc. Psychiatry 45 (10) (2006) 1171 e 1178 .[17]
M.W. Cunningham, Pathogenesis of group A streptococcal infections and their sequelae, Adv. Exp. Med. Biol. 609 (2008) 29 e 42.
[18]
H.S. Singer, J.J. Hong, D.Y. Yoon, P.N. Williams, Serum autoantibodies do not differentiate PANDAS and Tourette syndrome from controls, Neurology 65 (11) (2005) 1701 e 1707 .[19]
H.S. Singer, C. Gause, C. Morris, P. Lopez, Serial immune markers do not correlate with clinical exacerbations in pediatric autoimmune neuropsychi- atric disorders associated with streptococcal infections, Pediatrics 121 (6) (2008) 1198 e 1205 .[20]
A. Walls, M. Cubangbang, H. Wang, et al., Pediatric autoimmune neuropsy- chiatric disorder associated with Streptococcus immunology: a pilot study, Otolaryngol. Head Neck Surg. 153 (1) (2015) 130 e 136 .[21]
A. Walls, S. Dermody, R. Kumaran, N. Krishnan, E.H. Harley, Characterization of B-Cells in tonsils of patients diagnosed with pediatric autoimmune neuro- psychiatric disorder associated streptococcus, Int. J. Pediatr. Otorhinolaryngol. 80 (2016) 49 e 52.
[22]
E.A. Storch, T.K. Murphy, G.R. Geffken, et al., Reliability and validity of the Yale global tic severity scale, Psychol. Assess. 17 (4) (2005) 486 e 491 .[23]
J.A. Lopez-Pina, J. Sanchez-Meca, J.A. Lopez-Lopez, et al., The yale-brown obsessive compulsive scale: a reliability generalization meta-analysis, Assessment 22 (5) (2015) 619 e 628.
[24]
T.D. van Immerzeel, R.M. van Gilst, N.G. Hartwig, Bene fi cial use of immuno- globulins in the treatment of Sydenham chorea, Eur. J. Pediatr. 169 (9) (2010) 1151 e 1154 .Z. Farhood et al. / International Journal of Pediatric Otorhinolaryngology 89 (2016) 149
e
153
60