Differential Diagnosis

Other autoimmune illnesses that may cause sudden onset OCD include: Lyme disease, Thyroid disease, Celiac disease, Lupus, Sydenham Chorea, Kawasaki’s disease, and acute Rheumatic Fever.

Some children have been found to have immunology deficits such as IgG subclass deficiencies. Children will need to be evaluated for this issue by an immunologist.

Treatment strategies

Standard OCD Treatment

Standard therapies (SSRIs and cognitive behavioral therapy [CBT]) have some efficacy in the PANDAS/PANS subset of OCD, although well-controlled trials are lacking.

Studies of CBT have shown some efficacy with older PANDAS/ PANS children, but the main benefit seems to be that parents learned techniques for managing OCD exacerbations.

Some research suggests that children with PANDAS/PANS may experience higher behavioral activation rates on SSRIs. Other reports, however, suggest that OCD in patients with PANDAS/PANS respond to serotonergic drugs. There are not controlled studies on the use of antipsychotic augmentation in children in the PANDAS/ PANS subgroup.

immunotherapies

If PANDAS and a streptococcal infection are suspected, the individual can be treated with antibiotics such as penicillin, amoxicillin, azithromycin, and augmentin (standard dosing). Penicillin, aug- mentin, and azithromycin appear to be more clinically effective in clearing GABHS than amoxicillin. In some cases, parents have reported a behavioral/symptomatic improvement within 24 hours. Most patients, however, appear to need 10-12 days of antibiotics for improvement. About 3 weeks after completing treatment for strep, a new culture can be drawn.

Prophylaxis with antibiotics may prevent exacerbations of future symptoms but raises concerns about antibiotic-resistance.

Other acute treatment options include immunomodulat- ing therapy such as intravenous immunoglobulins (IVIG) and Plasmapheresis. Immunomodulating therapies do not appear to be effective for Tourette’s Syndrome or other non-PANDAS OCD cases.

With IVIG, immunoglobulin antibodies, type G, are extracted from donated blood and transferred to the recipient through an intravenous line. IVIG is used in many auto-immune diseases but the exact nature of how it works is not known. IVIG is highly anti-inflammatory and may help T-regulatory cells become re-activated to help remove anti-host antibodies. In addition, some of the infused antibodies may help recognize infected cells or bacteria that were missed by the recipient’s own antibodies. Expert neurological input is advised.

Plasmapheresis is a process of removing antibodies from the blood stream through filtration. Another donor’s plasma is added on the return so that new antibodies are added (similar to IVIG). Plasmapheresis is used in severe auto-immune diseases because it can address acute antibody levels.

Some evidence suggests that both IVIG and plasmaphersis have better long-term outcomes when followed up with prophylactic antibiotic use.

 
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