Written by Hannah Harp
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Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) is a poorly understood term for infection- or non-infection-triggered acute-onset neuropsychiatric symptoms. Here’s how to recognize and treat it.
PANS scan…
PANS involves the sudden onset of relapsing-remitting neuropsychiatric symptoms – especially obsessive compulsive disorder (OCD), avoidant/restrictive food intake disorder (ARFID), or tics – that are not consistent with other diagnoses. Etiology is hypothesized to be postinfectious autoimmunity (including PANDAS, Sydenham chorea, or others) or noninfectious autoimmunity. There is inadequate evidence regarding etiology, and no specific antibodies or predisposing infections have been identified.
Evaluation
The hallmark of PANS is its sudden and dramatic onset. Symptoms should not be persistent but relapsing/remitting. Differential diagnosis includes: primary OCD, anxiety, tics, autoimmune encephalitis, Tourette syndrome, anorexia nervosa, and Sydenham chorea. Primary psychiatric and tic disorders are far more common than PANS.
- Physical exam is usually normal aside from tics, inattention, and sometimes fine choreiform movements of the fingers. Alteration in cognition, seizures, or focal neurologic findings should prompt further evaluation for autoimmune encephalitis.
- Group A strep (GAS) throat culture is recommended only if there is symptomatic pharyngitis.
- Referrals for cognitive behavioral therapy (CBT) and psychiatric evaluation should be initiated quickly.
- The AAP currently recommends AGAINST the following laboratory tests: universal GAS testing, ASO titers, anti-DNAse B titers, ANA titers, Mycoplasma PCR, ESR/CRP, and Cunningham (autoantibody) panel, due to low specificity.
- MRI, EEG, and LP are NOT recommended unless there is concern for encephalitis.
Treatment
- Treatment includes standard psychiatric and behavioral therapy including CBT, SSRIs, OT/PT as needed.
- Treat GAS pharyngitis if evidence of bacterial infection; universal treatment or prolonged antibiotic courses are NOT recommended.
- Immunomodulators, IVIG, and plasma exchange are NOT recommended.
How this will change my practice?
In training, we learned about PANS as a nebulous “out there” diagnosis, so I’ve had little experience with the details. For example, I had no idea that ARFID can be a presenting symptom of PANS. I’ve yet to have any suspicion for PANS in a patient, but I will someday, and this guide will be extremely helpful.
Source
Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025 Mar 1;155(3):e2024070334. doi: 10.1542/peds.2024-070334. PMID: 39676248.
