CHICAGO — A new study suggests that three of the five criteria for inclusion in the pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS, subgroup could be narrowed and still provide clinically useful benchmarks.
The first criteria for this subgroup is that the children must meet a lifetime diagnostic criteria for obsessive-compulsive disorder (OCD) or a tic disorder, Lisa Snider, M.D., said at the annual meeting of the Society for Developmental and Behavioral Pediatrics.
“Some people are suggesting that anorexia nervosa, attention-deficit hyperactivity disorder, possibly even bipolar disorder could be triggered by infections like streptococcal infection,” Dr. Snider said. “Our research came out of a predisposition to thinking that OCD and tics are secondary to a dysfunction within the basal ganglia.
“Our original research was on patients with Sydenham's chorea, which is triggered by streptococcal infection, and felt to be a basal ganglia disorder.”
The criteria were defined in 1998 by colleague Susan Swedo, M.D., of the National Institute of Mental Health in Bethesda, Md. The criteria also have been used successfully to study the pathophysiology and clinical course of the PANDAS subgroup. But, some researchers have criticized the criteria as being too broad.
PANDAS is now defined by the presence of OCD and/or tic disorder, prepubertal onset, unique clinical course, association of neuropsychiatric symptoms with group A β-hemolytic streptococcal infections, and association with neurologic abnormalities during symptomatic periods.
Dr. Snider, along with some colleagues have suggested the three new criteria should be:
▸ A primary diagnosis of OCD or prominent obsessive-compulsive features (criterion 1).
▸ Abrupt onset of neuropsychiatric symptoms reaching clinical impairment in less than 48 hours or a period of complete neuropsychiatric symptom remission (criterion 2).
▸ A positive throat culture in the 2 months prior to or elevated antistreptococcal titers drawn between 3 weeks and 3 months after neuropsychiatric symptom onset or exacerbation (criterion 3).
“The criteria haven't radically changed, but they are tighter and much more specific, she said. That should help clinicians and researchers,” Dr. Snider told this publication. “If you see someone for the first time, you have a better chance now of saying if this is PANDAS or not, because we don't have a blood test for this disorder.”
The latest study included 30 boys and 20 girls, who met the original PANDAS criteria.
The mean age for the group was 8.2 years.
Thirty-eight of the patients (76%) had a primary diagnosis of OCD and 12 patients (24%) had a primary diagnosis of tic disorder.
Of the 12 patients with a primary tic disorder, 9 (75%) had comorbid OCD or significant obsessive-compulsive symptoms. Only three patients had a tic disorder without obsessive-compulsive features.
The results were equally clear with regard to criterion 2, Dr. Snider said. Forty-four of the 50 patients (88%) had an abrupt onset of symptoms reaching clinical impairment in less than 48 hours. Of the remaining six patients, four had at least one period of complete symptom remission.
Finally, each of the 50 patients reportedly had a group A β-hemolytic streptococcal infection, which was associated with onset or exacerbation. Infection was identified in 23% of patients at presentation. “Three of the five criteria for inclusion in the PANDAS subgroup could be narrowed and still include 95% of this cohort,” Dr. Snider said.