Understanding Panda Syndrome: Diagnosis And Treatment Options

PANDAS, or Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections, is a complex disorder with a wide range of symptoms that vary from patient to patient. The condition is the result of a Group A Streptococcal bacterial infection, commonly known as strep throat, which causes a child's immune system to attack their own brain. While there is no single definitive test for PANDAS, a combination of tests can help diagnose the disorder. These tests include strep cultures, allergy tests, immunological tests, brain scans, and the Cunningham panel, among others. In this article, we will explore the various tests used to diagnose PANDAS and provide an overview of the signs, symptoms, and treatment options for this often-misunderstood condition.

Testing for Strep Infection

Initial Testing

To confirm a strep infection, doctors typically start with a throat swab or throat culture to detect the presence of strep bacteria. This is a standard test for strep throat, which is a common infection associated with PANDAS. If the throat swab does not yield positive results, other testing methods are necessary.

Antibody Testing

Antibody tests, such as a rapid strep test or an antibody titre test, can help determine if your child has had a recent strep infection. These tests detect the presence of antibodies produced by the body to fight the strep bacteria. A positive result indicates a current or previous infection, which is relevant for PANDAS diagnosis.

Blood Tests

Blood tests are crucial in diagnosing strep infections, especially when the throat culture is negative. Blood tests can detect antibodies or other markers of infection, even if the child has recovered. They help confirm a recent strep infection and rule out other potential causes of symptoms.

Alternative Sites of Infection

If the initial tests are negative, doctors should explore other areas where strep bacteria may be hiding. This includes testing the sinuses, bottom, and genitals for the presence of strep. These sites can harbour strep infections that trigger PANDAS symptoms and often require more prolonged treatment.

Physical Examination and Medical History

In addition to laboratory tests, a thorough physical examination and evaluation of the child's symptoms are essential. PANDAS diagnosis also relies on a careful medical history, including the presence of obsessive-compulsive behaviours, tic disorders, neuropsychiatric symptoms, and a history of strep infection confirmed by throat culture or blood test.

Further Testing for PANS

If your child does not have strep, their symptoms may be related to PANS (paediatric acute-onset neuropsychiatric syndrome), which is triggered by infections other than strep, such as Lyme disease or influenza. In this case, your doctor may order additional blood tests or brain scans to identify the underlying cause of the symptoms.

Testing for Other Infections

Lyme disease, for example, can be tested for using CLIA-certified labs that are sensitive enough to detect multiple Borrelia species. Antibody testing can also be used to look for other infections such as Bartonella, Babesia, and Ehrlichia, as well as Epstein-Barr Virus (EBV), Coxsackie virus, HSV1 and 2, and Candida.

In addition to these tests, a complete blood count (CBC) can be performed to check for other infections and assess overall health. Urinalysis can also be used to rule out a urinary tract infection (UTI) when urinary complaints are present.

It is important to note that PANS/PANDAS is primarily a clinical diagnosis based on a thorough evaluation of a patient's medical history, symptoms, and physical examination. Laboratory tests are used to support the clinical diagnosis, rule out other potential causes, and inform treatment plans.

Testing the Immune Response

IgG, IgM, and IgA Levels:

Testing IgG, IgM, and IgA levels, including subclasses of IgG and IgA, can provide valuable information about the immune system's function. Low levels of these immunoglobulins may indicate a common variable immune deficiency (CVID), which has been associated with PANS/PANDAS.

IgG Antibody Responses to Immunizations:

Evaluating a child's IgG antibody responses to immunizations can be informative. If a child has received vaccinations but has not developed antibodies, it may suggest a specific antibody deficiency commonly seen in PANS/PANDAS patients.

Antinuclear Antibody (ANA) Testing:

ANA testing helps identify the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. A positive ANA test can indicate the presence of an autoimmune disorder, such as PANDAS/PANS.

Glutamic Acid Decarboxylase (GAD-65) Antibodies:

GAD-65 antibody testing is important because these antibodies are often found in individuals with autoimmune disorders, particularly those affecting the nervous system.

Complete Blood Count (CBC):

A CBC provides a comprehensive overview of the different types and numbers of cells in the blood, including red blood cells, white blood cells, and platelets. It can help identify infections, inflammation, or other abnormalities that may be contributing to PANS/PANDAS symptoms.

Urine Mycotoxin Tests:

Urine mycotoxin tests are used to detect exposure to mould, as mould toxins can impact the immune system and potentially trigger or exacerbate PANS/PANDAS symptoms.

EEG Testing and Brain Imaging:

EEG (electroencephalogram) testing helps evaluate the electrical activity in the brain, while brain imaging techniques such as PET and SPECT scans provide visual information about brain function and structure. These tests can help rule out other neurological conditions and identify any abnormalities associated with PANS/PANDAS.

It is important to note that PANS/PANDAS is a clinical diagnosis, and these tests support and supplement the behavioural changes and neurological signs identified by a specialist. The interpretation of these tests should be left to medical professionals, who can provide a comprehensive evaluation and determine the most appropriate treatment plan.

Other Laboratory Testing

• A complete blood count (CBC)
• Urine mycotoxin tests to look for a history of exposure to mould
• EEG testing and brain imaging, such as PET and SPECT scanning
• Antibody testing (IgG and IgM) for Epstein-Barr Virus (EBV)
• Antibody testing (IgG and IgM) for Coxsackie virus
• HSV1 and 2 antibodies
• Antibody testing (IgG, IgA, and IgM) for Candida
• A stool study to look for high levels of Candida

It is important to note that PANDAS/PANS is a clinical diagnosis and there is no single test to confirm it. The diagnosis is based on an analysis of the child's medical history, current symptoms, and physical examination. Laboratory tests and additional testing are used to identify an infectious trigger, rule out other diagnoses, and inform treatment plans.

EEG Testing and Brain Imaging

Electroencephalography (EEG) is a test that can be used to detect abnormal brain activity in PANDAS patients. An EEG test involves placing electrodes on the scalp to record brain activity. This test may be useful for demonstrating abnormal brain activity in PANDAS patients, who often experience sleep disturbances.

EEG tests can detect intermittent or persistent focal or generalized EEG alterations, which have been reported in 56% of PANDAS patients. Focal epileptiform activity has also been observed in some PANDAS patients.

In addition to EEG, brain imaging techniques such as magnetic resonance imaging (MRI) and positron emission tomography (PET) can be used to visualise brain structure and function. MRI scans of the cerebral cortex and basal ganglia in PANDAS patients have shown volumetric increases in these brain regions compared to healthy controls. These findings are consistent with the hypothesis that PANDAS is associated with inflammation of the basal ganglia.

Another imaging technique, voxel-based morphometry, has been used to demonstrate neuroanatomical differences in the grey and white matter of PANDAS patients compared to healthy controls.

Overall, EEG testing and brain imaging techniques can provide valuable information about brain function and structure in PANDAS patients, aiding in the diagnosis and understanding of this complex disorder.

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