The PANDAS Syndrome

  • Michael E. PichicheroEmail author
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 634)


PANDAS is an acronym for Pediatric Autoimmune Neurologic Disorders Associated with Streptococcus coined by Swedo et al. ( 1998) to describe a syndrome of symptoms to include a variable combination of obsessions, compulsions, tics, hyperactivity, inattention, and mild choreiform movements (Table 1). These symptoms affect children with a fluctuating course following Group A Streptococcal (GAS) tonsillo-pharyngitis and may reach sufficient severity to qualify for a diagnosis of obsessive–compulsive disorder (OCD), Tourette syndrome (TS), chronic tic disorder, attention-deficit/hyperactivity disorder (ADHD), or other diagnostic entities. Although estimating the frequency of PANDAS is difficult, some investigators believe that it may account for 10% or more of cases of childhood-onset OCD (Giuliano et al., 1998) and tic/TS (Cardona and Orefici, 2001). Growing clinical interest has spurred attempts to better define the PANDAS syndrome and develop new treatments for PANDAS. In...


Tourette Syndrome Acute Rheumatic Fever Throat Culture Rapid Antigen Detection Test Streptococcal Antigen 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Allen AJ, Leonard HL, Swedo SE. Case study: a new infection-triggered, autoimmune subtype of pediatric OCD and Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry 1995;34:307–311.PubMedCrossRefGoogle Scholar
  2. Cardona F. Orefici G. Group A streptococcal infections and tic disorders in an Italian pediatric population. J Pediatr 2001;138:71–75.PubMedCrossRefGoogle Scholar
  3. Chapman AH, Pilkey L, Gibbons MJ. A psychosomatic study of eight children with Sydenham’s chorea. Pediatrics 1958;21:582–595.PubMedGoogle Scholar
  4. Chappell P, Riddle M, Anderson G, Scahill L, Hardin M, Walker D et al. Enhanced stress responsively of Tourette syndrome patients undergoing lumbar puncture. Biol Psychiatry 1994;36(1):35–43.PubMedCrossRefGoogle Scholar
  5. Church AJ, Dale RC, Lees AJ, Giovannoni G, Robertson MM. Tourette’s syndrome: a cross sectional study to examine the PANDAS hypothesis. J Neurol Neurosurg Psychiatry 2003;74:602–607.PubMedCrossRefGoogle Scholar
  6. Church AJ, Dale RC, Giovannoni G. Anti-basal ganglia antibodies: a possible diagnostic utility in idiopathic movement disorders? Arch Dis Child 2004;89:611–614.PubMedCrossRefGoogle Scholar
  7. Cunningham MW. Pathogenesis of group A streptococcal infections. Clin Microbiol Rev 2000;13(3):470–511.PubMedCrossRefGoogle Scholar
  8. Dale RC, Heyman I, Giovannoni G, Church AJ. Incidence of anti-brain antibodies in children with obsessive-compulsive disorder. Br J Psychiatry 2005;187:314–319.PubMedCrossRefGoogle Scholar
  9. Dale RC, Candler PM, Church AJ et al. Neuronal surface glycolytic enzymes are autoantigen targets in post-streptococcal autnoimmune CNS disease. J. Neuroimmunol 2006;172:187–197.PubMedCrossRefGoogle Scholar
  10. Garvey MA, Perlmutter SJ, Allen AJ, Hamburger S, Lougee L, Leonard HL et al. A piolot study of penicillin prophylaxis for neuropsychiatric exacerbatioins triggered by streptococcal infections. Biol Psychiatry 1999;45:1564–1571.PubMedCrossRefGoogle Scholar
  11. Giedd JN, Rapoport JL, Kruesi MJ, Parker C, Schapiro MB, Allen AJ et al. Sydenham’s chorea: magnetic resonance imaging of the basal ganglia. Neurology 1995;45(12):2199–2202.PubMedGoogle Scholar
  12. Giedd JN, Rapoport JL, Leonard HL, Richter D, Swedo SE. Case study: acute basal ganglia enlargement and obsessive-compulsive symptoms in an adolescent boy. J Am Acad Child Adolesc Psychiatry 1996;35(7):913–915.PubMedCrossRefGoogle Scholar
  13. Giuliano JD, Zimmerman A, Walkup JT, Singer HS. Prevalence of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection by history in a consecutive series of community referred children evaluated for tics. Ann Neurol. 1998;44(3):556.Google Scholar
  14. Hallett JJ, Harling-Berg CJ, Knopf PM, Stopa EG, Kiessling LS. Anti-striatal antibodies in Tourette syndrome cause neuronal dysfunction. J Neuroimmunol 2000;111(1–2):195–202.PubMedCrossRefGoogle Scholar
  15. Husby G, van dRI, Zabriskie JB, Abdin ZH, Williams RC, Jr. Antibodies reacting with cytoplasm of subthalamic and caudate nuclei neurons in chorea and acute rheumatic fever. J Exp Med 1976;144(4):1094–1110.PubMedCrossRefGoogle Scholar
  16. Kaplan MH. Autoantibodies to heart and rheumatic fever: the induction of autoimmunity to heart by streptococcal antigen cross-reactive with heart. Ann N Y Acad Sci 1965;124(2):904–915.PubMedCrossRefGoogle Scholar
  17. Kaplan EL, Rothermel CD, Johnson DR. Antistreptolysin O and antideoxyribonuclease B titers: normal values for children ages 2 to 12 in the United States. Pediatrics 1998;101(1 Pt 1):86–88.PubMedCrossRefGoogle Scholar
  18. Kienzle GD, Breger RK, Chun RW, Zupanc ML, Sackett JF. Sydenham chorea: MR manifestations in two cases. AJNR Am J Neuroradiol 1991;12(1):73–76.PubMedGoogle Scholar
  19. Kiessling et al. Speculations on Antineural Antibody-mediated Neuropsychiatric Disorders of Childhood. Pediatr 1994; 93:323–326.Google Scholar
  20. Kiessling LS, Marcotte AC, Culpepper L. Antineuronal antibodies in movement disorders. Pediatrics 1993;92(1):39–43.PubMedGoogle Scholar
  21. Kiessling LS, Marcotte AC, Culpepper L. Antineuronal antibodies: tics and obsessive-compulsive symptoms. J Dev Behav Pediatr 1994;15(6):421–425.PubMedCrossRefGoogle Scholar
  22. Kirvan CA, Swedo SE, Snider LA, Cunningham MW. Antibody-mediated neuronal cell signaling in behavior and movement disorders. J Neuroimmunol 2006;179:173–179.PubMedCrossRefGoogle Scholar
  23. Klieger PS, Fett KA, Dimitsopulos T, Karlan R. Asymmetry of basal ganglia perfusion in Tourette’s syndrome shown by technetium-99 m-HMPAO SPECT. J Nucl Med 1997;38:188–191.PubMedGoogle Scholar
  24. Kurlan R. Tourette’s syndrome and “PANDAS”: will the relation bear out? Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection. Neurology 1998;50(6):1530–1534.PubMedGoogle Scholar
  25. Kurlan R, Kaplan EL. The Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection (PANDAS) Etiology for Tics and Obsessive-Compulsive Symptoms: Hypothesis or Entity? Practical Considerations for the Clinician. Pediatr 2004;113:883–886.Google Scholar
  26. Lin H, Yeh C-B, Peterson BS, Scahill L, Grantz H, Findley DB et al. Assessment of symptom exacerbations in a longitudinal study of children with Tourette syndrome or obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 2002;41.Google Scholar
  27. Lougee L, Perlmutter SJ, Nicolson R, Garvey MA, Swedo SE. Psychiatric disorders in first-degree relatives of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). J Am Acad Child Adolesc Psychiatry 2000;39(9):1120–1126.PubMedCrossRefGoogle Scholar
  28. Luo F, Leckman JF, Katsovich L et al. Prospective longitudinal study of children with tic disorders and/or obsessive-compulsive disorder: relationship of symptom exacerbations to newly acquired streptococcal infections. Pediatrics 2004;113(6):e578–e585.PubMedCrossRefGoogle Scholar
  29. Mell LK, Davis RL, Ownes D. Association between streptococcal infection and obsessive-compulsive disorder, Tourette’s syndrome, and tic disorder. Pediatrics 2005;116(1):56–60.PubMedCrossRefGoogle Scholar
  30. Morshed SA, Parveen S, Leckman JF, Mercadante MT et al. Antibodies against neural, nuclear, cytoskeletal, and streptococcal epitopes in children and adults with Tourette’s syndrome, Sydenham’s chorea, and autoimmune disorders. Biol Psychiatry 2001;50:566–577.PubMedCrossRefGoogle Scholar
  31. Murphy TK, Goodman WK, Fudge MW, Williams RC, Jr, Ayoub EM, Dalal M et al. B lymphocyte antigen D8/17: a peripheral marker for childhood-onset obsessive-compulsive disorder and Tourette’s syndrome? Am J Psychiatry 1997;154(3):402–407.PubMedGoogle Scholar
  32. Murphy TK, Goodman WK, Ayoub EM, Voeller KK. On defining Sydenham’s chorea: where do we draw the line? Biol Psychiatry 2000;47(10):851–857.PubMedCrossRefGoogle Scholar
  33. Murphy ML, Pichichero ME. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med 2002;156:356–361.PubMedGoogle Scholar
  34. Orvidas LJ, Slattery MJ. Pediatric autoimmune neuropsychiatric disorders and streptococcal infections: role of otolaryngologist. Laryngoscope 2001;111(9):1515–1519.PubMedCrossRefGoogle Scholar
  35. O’Sullivan RL, Rauch SL, Breiter HC et al. Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging. Biol Psychiatry 1997;42:39–45.PubMedCrossRefGoogle Scholar
  36. Pauls DL. Update on the genetics of Tourette syndrome. Adv Neurol 2001;85:281–293.PubMedGoogle Scholar
  37. Pauls DL, Raymond CL, Stevenson JM, Leckman JF. A family study of Gilles de la Tourette syndrome. Am J Hum Genet 1991;48(1):154–163.PubMedGoogle Scholar
  38. Perlmutter SJ, Leitman SF, Garvey MA, Hamburger S, Feldman E, Leonard HL et al. Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood. Lancet 1999;354(9185):1153–1158.PubMedCrossRefGoogle Scholar
  39. Perrin EM, Murphy ML, Casey JR, Pichichero ME, Runyan DK, Miller WC, Snider LA, Swedo SE. Does group A b-hemolytic streptococcal infection increase risk for behavioral and neuropsychiatric symptoms in children? Arch Pediatr Adolesc Med 2004;158:848–856.PubMedCrossRefGoogle Scholar
  40. Peterson BS. Neuroimaging in child and adolescent neuropsychatric disorders. J Am Acad Child Adolesc Psychiatry 1995;34:1560–1576.PubMedCrossRefGoogle Scholar
  41. Peterson BS, Leckman JF, Tucker D, Scahill L, Staib L, Zhang H et al. Preliminary findings of antistreptococcal antibody titers and basal ganglia volumes in tic, obsessive-compulsive, and attention deficit/hyperactivity disorders. Arch Gen Psychiatry 2000;57(4):364–372.PubMedCrossRefGoogle Scholar
  42. Rasmussen SA, Tsuang MT. Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. Am J Psychiatry 1986;143(3):317–322.PubMedGoogle Scholar
  43. Singer HS, Giuliano JD, Hansen BH, Hallett JJ, Laurino JP, Benson M et al. Antibodies against human putamen in children with Tourette syndrome. Neurology 1998;50(6):1618–1624.PubMedGoogle Scholar
  44. Singer HS. PANDAS and immunomodulatory therapy. Lancet 1999;354(9185):1137–1138.PubMedCrossRefGoogle Scholar
  45. Snider LA, Seligman LD, Ketchen BR et al. Tics and problem behaviors in schoolchildren: prevalence, characterization, and associations. Pediatrics 2002;110:331–336.PubMedCrossRefGoogle Scholar
  46. Snider LA, Lougee L, Slattery M, Grant P, Swedo SE. Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders. Biol Psychiatry 2005;57:788–792.PubMedCrossRefGoogle Scholar
  47. Stollerman GH. Rheumatic fever and streptococcal infection: unraveling the mysteries of a dread disease. Boston: 1997.Google Scholar
  48. Swedo SE. Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Clinical Description of the First 50 Cases. Am J Psychiatry 1998;155:264–271.Google Scholar
  49. Swedo SE. The Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection (PANDAS) Subgroup: Separating Fact from Fiction. Pediatr 2004; 113:907–911.Google Scholar
  50. Swedo SE, Rapoport JL, Cheslow DL, Leonard HL, Ayoub EM, Hosier DM et al. High prevalence of obsessive-compulsive symptoms in patients with Sydenham’s chorea. Am J Psychiatry 1989;146(2):246–249.PubMedGoogle Scholar
  51. Swedo SE, Rapoport JL, Leonard H, Lenane M, Cheslow D. Obsessive-compulsive disorder in children and adolescents: clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989;46:335–341.PubMedCrossRefGoogle Scholar
  52. Swedo et al. Syndenharn’s Chorea: a Model for Childhood Autoimmune Neuropsychiatric Disorders. JAMA 1994;272:1788–1791.Google Scholar
  53. Swedo SE, Leonard HL, Kiessling LS. Speculations on antineuronal antibody-mediated neuropsychiatric disorders of childhood. Pediatrics 1994;93:323–326.PubMedGoogle Scholar
  54. Swedo SE, Leonard HL, Mittleman BB et al. Identification of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections by a marker associated with rheumatic fever. Am J Psychiatry 1997;154:110–112.PubMedGoogle Scholar
  55. Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry 1998;155(2):264–271.PubMedGoogle Scholar
  56. Traill Z, Pike M, Byrne J. Sydenham’s chorea: a case showing reversible striatal abnormalities on CT and MRI. Dev Med Child Neurol 1995;37(3):270–273.PubMedCrossRefGoogle Scholar
  57. Trifiletti RR. TS83: Candidate target brain autoantigen in Tourette Syndrome and OCD. Ann. Neurol. 1998;44(3):561.Google Scholar
  58. Trifiletti RR, Altemus M, Packard AM, Bandele AN, Zabriskie JB. Changes in Antineuronal Antibodies following conventional and immunosuppressive therapy for Tourette’s syndrome and obsessive-compulsive disorder. Ann. Neurol. 1998;44(3):561.Google Scholar

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© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.University of Rochester Medical CenterRochesterUSA

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