for clinical exacerbations than the control group , but that the result was not statistically significant . 6
Other authors have commented that the relationship between prior GAS infection and obsessive-compulsive disorder ( OCD ) or tics / Tourette ’ s syndrome in childhood is not as clear . Studies summarized in a paper by Shulman include a prospective cohort study that found that more than 85 % of clinical exacerbations in OCD / tic behavior in patients who met criteria for PANDAS had no relationship to GAS infection . Another study found no correlation between clinical exacerbations and changes in a variety of markers of brain autoimmunity . A third study concluded that , compared with specialty clinics diagnoses , patients diagnosed with tics or Tourette ’ s by physicians in the community were significantly more likely to be diagnosed with PANDAS ; without meeting the proposed criteria , most lacked supporting laboratory evidence of GAS infection , and they were more likely to be treated with unjustified short-term-to-chronic antibiotic and / or immunomodulatory therapy . 7
Table 2 DIAGNOSTIC CRITERIA FOR PANS 8 a ) Abrupt , dramatic onset of OCD or severely restricted food intake . b ) Concurrent presence of additional neuropsychiatric symptoms , with similarly severe and acute onset , from at least two of the following seven categories : 1 . anxiety , 2 . emotional lability and / or depression , 3 . irritability , aggression , and / or severely oppositional behaviors , 4 . Behavioral ( developmental ) regression , 5 . Deterioration in school performance , 6 . Sensory or motor abnormalities , 7 . Somatic signs and symptoms , including sleep disturbances , bedwetting , or increased urinary frequency . c ) Symptoms are not better explained by a known neurologic or medical disorder , such as Sydenham chorea , SLE , Tourette ’ s Syndrome , or others .
Therefore , in July 2010 , a group of experts modified the term PANDAS to PANS-Pediatric Acute-onset Neuropsychiatric Syndrome . Diagnostic criteria are summarized in Table 2 . 8 The proposed pathophysiology of this disorder is similar to that for PANDAS , that is , a parainfectious or autoimmune inflammatory process affecting the basal ganglia . The exception is that the specific trigger is undefined and is not restricted to a GAS infection . The term PITAND , or Pediatric Infection Triggered Autoimmune Neuropsychiatric Disorder , is sometimes used interchangeably for PANS .
Diagnosis
Most experts believe that the diagnosis of PANS should be restricted to patients who meet the clinical criteria laid out in Table 2 . Recently , the Cunningham panel has been proposed as a serologic diagnostic marker for PANS . The panel is composed of five tests : anti-dopamine receptor D1 titer , anti-dopamine receptor D2 titer , anti-lysogangioside GM1 titer , anti-tubulin titer , and CAM KINASE II % of baseline . Results are expressed as whether the level of a particular antibody falls inside or outside the normal range . A num-
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Volume 117 • Number 9 March 2021 • 207