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Online First                                                                                                                      Indian J Pharm Drug Studies | 1  

Case report 

A case of pediatric autoimmune neuropsychiatric disorder associated with 

streptococcal infection  

Dr. Reshma R1, Dr. Ajnas K1 

From, 1Clinical Pharmacist, Department of Prescription Audit, Indraprastha Apollo Hospital, Delhi, India 

ABSTRACT 

Pediatric autoimmune neuropsychiatric disease associated with streptococcal infection (PANDAS), is a subtype of acute-onset 

obsessive-compulsive disorder (OCD) induced by an immunological reaction to group A streptococcal infection. These diseases may 

be worsen by an autoimmune response brought on by streptococcal infections. One of the recurring diseases linked to PANDAS is 

recurrent streptococcal tonsillitis. "Strep throat" (acute suppurative tonsillitis) is a tonsil infection typically caused by Group A Beta-

Hemolytic Streptococci (GABHS) bacteria, often leading to intense throat pain, fever, and difficulty swallowing for a few days. 

Health care providers frequently use a rapid strep test to check the tonsils of patients experiencing a sore throat for GABHS, as 

untreated infections can lead to more severe health issues. Occasionally, strep throat can result in a body rash (known as scarlet fever) 

and can also lead to more severe health issues such as arthritis in children, rheumatic fever that can cause long-lasting heart problems, 

and post-streptococcal glomerulonephritis which may result in kidney failure. Here we present a case of 20-year-old male patient with 

PANDAS, who underwent tonsillectomy. The morbidity associated with this neuropsychiatric condition can be reduced with prompt 

management. 

Key words: Obsessive compulsive disorder, Tonsillectomy, Streptococcal infection 

ediatric autoimmune neuropsychiatric diseases 

associated with streptococcus (PANDAS), which 

explains a collection of illnesses, including scarlet 

fever and strep throat, that are believed to afflict certain 

children who have streptococcal infections. Although a direct 

correlation has not yet been shown, there have been some 

reports of tics, obsessive-compulsive behaviour, and other 

neurological and mental symptoms developing following 

PANDAS. Following an infection with Streptococcus 

pyogenes, children experience abrupt and typically substantial 

changes in personality, behaviour, and mobility. 1 

The signs and symptoms occur during a PANDAS 

episodes are Moodiness and irritability, Separation anxiety, 

ADHD (Attention Deficit Hyperactivity Disorder)symptoms, 

Sleep disturbances, Night-time bed wetting and/or day-time 

urinary frequency, Fine motor changes (writing), Joint pain, 

Trouble eating, Concentration difficulties and loss of 

academic abilities. Children may have tics, which are 

uncontrollable, abrupt motions or sounds that they repeatedly 

make. They could jerk their head or blink a lot. They could 

repeat sentences, growl, or continuously clear their throat. The 

child's immune system generates antibodies that specifically 

attack GABHS bacteria when they are infected. In PANDAS,  

Access this article online 

 

Received –  27th July 2024 

Initial Review –  27th September 2024 

Accepted – 29th November 2024 

Quick Response Code 

it is thought that these antibodies also coincidentally target 

and cause inflammation in a region of the brain known as the 

basal ganglia. This region of the brain is responsible for 

refining deliberate muscle actions and managing behaviour 

within the realm of thinking and logic. If this area of the brain 

is affected, its performance decreases and changes, leading to 

specific involuntary actions and motions. 

To determine whether the kid has PANDAS, which can 

resemble other diseases, a strep bacterial test or a history of 

the bacterium is required. The doctor should examine 

additional areas where strep tends to hide, such as the sinuses 

or child's genitalia and but if a throat swab or antibody test 

yields no results. Even if the child recovered, a blood test 

might reveal if they had a recent strep infection. If child does 

not or did not have strep throat, then they do not have 

PANDAS. However, their symptoms may still be a result of a 

malfunctioning immune system response. PANDAS is a 

member of a broader category of autoimmune illnesses 

impacting the brain known as pediatric acute-onset 

neuropsychiatric syndrome (PANS). The symptoms may be 

alike, but they could be caused by a different factor rather than 

strep. Physician might request blood tests or brain scans to 

determine if another infection or a different underlying cause 

is responsible for the symptoms.2,3 

__________________________________________________ 

Correspondence to: Dr. Ajnas K. Department of Prescription 

Audit, Indraprastha Apollo Hospital, Delhi, India. 

Email: ajnas.kth@gmail.com 

P 

http://www.nlm.nih.gov/medlineplus/ency/article/001551.htm
mailto:ajnas.kth@gmail.com


R and K                                                                                                                                  A case on PANDAS syndrome 

Online First                                                                                                                      Indian J Pharm Drug Studies | 2  

Despite its rarity, some experts believe it may be 

responsible for 10% of childhood obsessive-compulsive 

disorder (OCD) and tic disorders. 4 It affects roughly 1 in 1000 

children, and boys are three times more likely than girls to get 

it. Because most children have established streptococcus 

immunity by adolescence, it is considered a pre-pubertal 

condition. As a result, the onset is unlikely to occur again, 

while PANDAS symptoms may continue to appear on a 

regular basis.5 The National Institute of Mental Health’s 

(NIMH) criteria for PANDAS includes: 6  

1. Presence of tic disorder and/or OCD (obsessive 

compulsive disorder) 

2. Prepubertal onset of neuropsychiatric symptoms  

3. Abrupt onset and a course characterized by dramatic 

exacerbations 

4. The onset or exacerbation is temporally related to group A 

beta haemolytic streptococci (GABHS) infection 

5. Neurological abnormalities- hyperactivity, fidgetiness, 

restlessness or abnormal movements such as choreiform 

movements may be present during symptom exacerbation. 

The principle evidence-based therapies for OCD are 

cognitive behaviour therapy (CBT), which includes exposure 

and response prevention (ERP), and selective serotonin 

reuptake inhibitors (SSRIs). 7 Antibiotics or tonsillectomy to 

treat and/or prevent GABHS infection are additional or 

alternative therapy options when PANDAS is suspected. 8 

Therapeutic plasma exchange (TPE), intravenous 

immunoglobulin (IVIG), or anti-CD20 monoclonal antibodies 

(rituximab) have been used to suppress the immune system in 

patients with potential autoimmune-based OCD 

corticosteroids. 9 Nonsteroidal anti-inflammatory medicines 

(NSAIDs) have also been recommended to help with the 

psychiatric symptoms of PANDAS and PANS, which is in 

keeping with the autoimmune etiology explanation. 10 

CASE REPORT 

A 20-year old male patient was admitted to neurological 

department, who had history of episodes of sudden staring 

with deviation of right eye to right side in 2002, when he was 

2-year-old and was diagnosed as probable absence seizure 

though no treatment was started. While initially, these 

episodes were 1-2 per day, these increased to 5-10 episodes 

per day over a period of two years, and patient was put on 

valparin. He had history of aggressive behaviour, which 

would increase in presence of any infection (had two attacks 

of hand-foot-mouth disease <5-year age, croup at 6-year age) 

with EEG report of parieto-occipital spikes and MRI brain 

showing no significant abnormality, and he was diagnosed as 

having probable ADHD (Attention-Deficit/Hyperactivity 

Disorder). From 2006 onwards (6-year age), he started having 

behaviour disturbances with fluctuating mood, biting clothes, 

bruxism. He underwent squint surgery in 2008. Since 2010 

(10-year age), he had significant worsening of scholastic 

performance, would drink milk excessively, developed slurred 

speech, memory issues and episodes of bed wetting.  

Over the years, he developed abnormal eye movements, 

delayed speech and language and was diagnosed as regressive 

autism and homeopathic treatment was started. In 2014 (14-

year age), he had increase in aggressive behaviour and was 

taken to USA for further management. In 2019, Cunningham 

panel- anti dopamine receptor D1 increased; anti-tubulin 

increased; anti-dopamine receptor D2 normal. He had received 

Rituximab, IV steroid, IV-Ig, Bortezomib. CSF was negative 

for IgLON 5 antibody, GFAP, GABA-B, NMDA Glutamate 

receptor antibody, CASPR 2, Protein 2, LGI 1, AMPA-1 & 2 

antibodies. Lupus anticoagulant was negative. FDG-PET MRI 

whole body on 21th February 2021- hyper metabolism in 

bilateral striatal nuclei- consistent with limbic encephalitis. He 

was diagnosed as auto immune encephalitis- G6PD 

deficiency- seborrheic dermatitis- PANDAS (Pediatric 

Autoimmune Neuropsychiatric Disorder Associated with 

Streptococcal infection). He was on Tab.Clonidine 0.1 mg, 

Tab. Divalproex 250 mg, Tab. Risperidone 1 mg. He had 

received 9 doses of rituximab (last- 29th April 2021), 7 cycles 

of Bortezomib (last- 19th July 2021) and he was on regular IV 

Ig monthly (last- 1-3rd September 2021) and weekly IV methyl 

prednisolone.  

Therapeutic plasma exchange is the primary treatment for 

severe and life-threatening PANDAS, and may be used alone 

or alongside IVIG, high-dose IV corticosteroids, and/or 

rituximab. Along with IVIG, patients were given preventive 

antibiotics to avoid worsening of symptoms triggered by 

infection in the future. They were also provided with typical 

psychiatric treatment, which involved utilizing anti-

obsessional drugs and cognitive-behavioural therapy. In order 

to achieve the best relief from symptoms, a combination of 

immunomodulatory therapy, antibiotic prophylaxis, and 

targeted symptom treatments is essential.  

Patient thus came to our neurology department for further 

evaluation on 7th September 2021. On examination, the patient 

was conscious and agitated, with bilateral plantar flexor 

response and no signs of neck rigidity. Routine investigation- 

vitamin B12-657, ammonia-42, vitamin D-70.04, TSH-3.15, 

C-reactive protein (CRP)- negative, Antistreptolysin O (ASO) 

titre- positive (215.07 IU/ml). Patient was managed with 

continuation of Tab.Resperidal 1 mg, Tab. Clonidine 0.1 mg, 

tab. Divalproex 250 mg. patient was discharged on 13th 

September 2021 with advice for OPD follow up and review 

with plan for FDG PET MRI and monthly IVIg. Patient was 

again admitted for IVIg therapy between 29th September to 4th 

October 2021 and discharged in stable condition and again 

admitted for monthly IVIg cycle (total 120g over 3 days) on 

12th November 2021 and patient was managed with ongoing 

treatment and was discharged on 15th November 2021 with 

advice for OPD follow up and next IVIg after 6 weeks (2g/kg 

total dose, divided over 3 days). 



R and K                                                                                                                                  A case on PANDAS syndrome 

Online First                                                                                                                      Indian J Pharm Drug Studies | 3  

On 7th December 2021, patient was admitted for 

tonsillectomy. During the admission, routine hematological 

and biochemical investigations were normal. Serum ASO 

(Antistreptolysin O) titre and CRP (C-reactive protein) were 

negative. Gram stain, fungal stain, AFB stain and stain for 

cryptosporidium and nocardia were negative from tonsillar 

pus. Serum EBV virus and HV virus RT PCR were negative. 

Aerobic culture from tonsillar pus show growth of alpha 

hemolytic streptococci, klebsiella, E.coli, rest fungal and 

AFB. Anerobic culture shows no growth. Serum TPO and 

anti-thyroid antibody was positive on background of T3-3.2, 

T4-1.44 and TSH-5.76.  

Patient was managed with appropriate antibiotics, 

antipsychotics, thyroid replacement and other symptomatic 

and supportive treatment. On 29th December 2021, patient was 

again admitted for IVIg therapy. Immunoglobulin immunorel-

10 10g (total 10 vials) thrice a day for 3 days were given. 

Serum TSH-1.06, T4-1.48, T3-3.5. Advised Tab.Erythrocin 

250 mg twice a day to continue as streptococcal prophylaxis. 

After receiving the full course of IVIg therapy, the patient was 

discharged in a stable condition. Follow up advised after one 

month. Patient condition improved and no notable symptoms 

showed. 

DISCUSSION 

During childhood, tics and obsessive-compulsive disorders 

(OCD) are rather frequent. They affect 1% to 4% of the 

pediatric population and 2% to 3% of the pediatric population, 

respectively.11 Swedo12 discovered a subset of patients whose 

tics and/or obsessive-compulsive disorder worsened briefly 

following group A beta hemolytic Streptococcus infections. 

The acronym PANDAS has been coined to describe this 

illness.12 Anxiety, emotional lability, focus issues, 

hyperactivity, and other symptoms are common in these 

patients.13 Our patient had a background of autoimmune 

encephalitis following criterias of prepubertal onset of 

neuropsychiatric manifestations, vocal repetitive spells (tics 

disorder), temporal association between onset or exacerbation 

of symptoms and prior infection. 

Orvidas et al13 reported two clinical cases of two siblings 

who suffer from recurrent tonsillitis as well as the PANDAS 

syndrome. Due to repeated streptococcal pharyngitis, two 

siblings—one with a tic problem and the other with obsessive-

compulsive disorder (OCD)—had tonsillectomy. Both patients 

showed notable improvement in their mental health conditions 

at the most recent follow-up appointment, which was held 11 

months after surgery. Their neuropsychiatric problems 

resolved after their tonsillectomy.13 Heubi et al14 describe 

clinical improvement in two patients with OCD and tics who 

had recurrent tonsillitis. Two siblings who met the criteria for 

the diagnosis of PANDAS and had recurrent tonsillitis whose 

symptoms, which were linked to TS and OCD, were made 

worse by tonsil infections. According to the PANDAS 

diagnostic criteria, a patient must already had a neurological 

disorder, usually TS or OCD. Patients with problematic 

obsessions and compulsions were said to have OCD, here 

their tonsils were removed.14 

Our patient also underwent tonsillectomy to prevent 

further throat infection. We presented this case to increase 

awareness of this disorder, which can lead to major declines in 

academic performance and social adjustment in prepubescent 

and early adolescent children. After taking antibiotics, some 

kid’s condition improves fast, but if they have streptococcal 

infection again, their symptoms can reappear. The majority 

recover with few long-term problems. For others, it may 

develop into a persistent issue that need the occasional 

prescription of antibiotics to manage infections that might 

result in flare-ups. Some children may be unable to function in 

social or academic settings due to PANDAS symptoms. If left 

untreated, PANDAS symptoms might get worse and cause 

irreversible cognitive impairment, thus can develop into a 

chronic autoimmune disease in certain children. 

CONCLUSION 

Limited reports of PANDAS in India may stem from 

inadequate awareness and under-recognition among healthcare 

providers. In any child presenting with abrupt onset or 

exacerbation of tics, OCD or late onset of Attention-

Deficit/Hyperactivity Disorder (ADHD), clinicians need to 

focus on the history of throat infection and evidence for 

GABHS infection. PANDAS is a condition characterized by 

episodic episodes that can resolve spontaneously; if the child 

is not in distress or facing disruptions in daily activities, 

observation may be enough. Early consideration of 

immunomodulatory therapy is recommended, as NSAIDs or a 

brief course of oral corticosteroids may be effective for 

symptom relief in new cases, while individuals with long-

standing symptoms may need more intensive and prolonged 

immunotherapeutic treatments. A proper cross referral 

between the pediatricians and the psychiatrists can aid in 

minimizing and eliminating the morbidity and the impairment 

which are connected with this disease. 

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R and K                                                                                                                                  A case on PANDAS syndrome 

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How to cite this article: Dr. Reshma R, Dr. Ajnas K. A case 

of pediatric autoimmune neuropsychiatric disorder associated 

with streptococcal infection. Indian J Pharm Drug Studies. 

2024; Online First. 

Funding: None;                 Conflicts of Interest: None Stated 

 

 

https://doi.org/10.1093/tropej/fmn039

