Testing For Pans: A Comprehensive Guide To Diagnosis

PANS (pediatric acute-onset neuropsychiatric syndrome) is a clinical diagnosis given to children who experience a dramatic and almost overnight onset of neuropsychiatric symptoms, including obsessive-compulsive disorder (OCD) and/or eating disorders. PANS can be triggered by various infections, metabolic disturbances, and other inflammatory reactions, and it is often challenging to recognise due to overlapping symptoms with other medical conditions. While there is no single definitive test for PANS, a combination of clinical evaluation, medical history, and laboratory findings can aid in making a proper diagnosis. If PANS is suspected, medical professionals may recommend a range of tests, including viral/bacterial testing, autoimmune antibody level assessments, and blood work to rule out other potential causes and confirm the presence of inflammatory markers.

Blood tests for inflammation

Inflammation markers that can be measured through blood tests include:

• Erythrocyte sedimentation rate (ESR): This test measures how quickly red blood cells settle at the bottom of a vertical tube of blood. When there is inflammation, red blood cells fall faster due to higher amounts of proteins causing the cells to clump together. A normal result is typically 20 mm/hr or less, while a value over 100 mm/hr is considered high.
• C-reactive protein (CRP): Produced in the liver, this protein tends to increase during inflammation. A normal value is less than 3 mg/L, while a value over 3 mg/L may indicate an increased risk of cardiovascular disease.
• Ferritin: This blood protein reflects iron levels in the body. It is often used to assess whether an anemic person is iron-deficient or has excess iron. Ferritin levels also tend to rise during inflammation. Normal results vary by lab, but a typical range is 20 to 200 mcg/L.
• Fibrinogen: While primarily measured to evaluate the blood clotting system, fibrinogen levels also tend to rise during inflammation. A normal fibrinogen level is between 200 and 400 mg/dL.

In addition to these inflammation markers, other blood tests that can aid in the diagnosis of PANS/PANDAS include basic blood work, such as IgA, IgM, IgG, B12, and vitamin D levels, as well as viral and bacterial testing for infections like strep throat, Lyme disease, and mycoplasma pneumoniae.

Throat swab for strep

A throat swab culture is a test to detect the presence of group A streptococcus bacteria, which is the most common cause of strep throat. These bacteria can also cause other infections, such as scarlet fever, abscesses, and pneumonia. A throat swab is the easiest and least invasive way to test for strep throat.

During the test, a healthcare provider will ask the patient to open their mouth as wide as possible. They will then use a flat stick to press down on the patient's tongue to get a clear view of the mouth and throat. Using a clean, soft cotton swab, they will lightly brush over the back of the throat, around the tonsils, and over any red or sore areas to collect a sample. The swabbing process only takes a few seconds and may cause slight discomfort or a gagging sensation.

The sample collected from the throat is then placed on a special plate (culture) that allows bacteria to grow in a laboratory setting. If the bacteria do not grow, the culture is negative, indicating the absence of a strep throat infection. On the other hand, if group A streptococcus bacteria are detected, it is likely that they are causing the sore throat or rash, and the patient will usually be prescribed antibiotics.

It is important to note that a throat swab culture may not always be necessary. In some cases, healthcare providers may opt for a rapid strep test, which can provide results within minutes. However, if the rapid strep test comes back negative, a throat culture may be recommended to confirm the results, as it is more accurate but takes longer (around 2-3 days) to process.

If a child or a family member tests positive for strep, it is advisable to schedule a follow-up strep test two weeks after completing the prescribed antibiotics to ensure the infection has cleared. Testing all family members is crucial to identify asymptomatic individuals or possible strep carriers, reducing the chances of re-infection.

Blood test for strep antibodies

PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) is a clinical diagnosis based on a collection of signs, symptoms, medical history, and laboratory findings that cannot be explained by any other neurological or medical disorders. There is currently no 100% definitive test for PANS, but blood tests can be carried out to aid diagnosis.

Blood tests for strep antibodies can be used to check for a strep infection. When you come into contact with harmful bacteria, your body produces antibodies to defend itself against these bacteria. Your body produces antibodies specific to the bacteria they fight.

The ASO titer test measures antibodies produced by your body in response to a toxin known as streptolysin O. Streptolysin O is a toxin produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria.

The ASO titer test can help your doctor determine if you recently had a strep infection by measuring the presence of antistreptolysin antibodies in your blood. If you have symptoms of post-streptococcal complications, your doctor will order the ASO titer test. Some common complications of strep include bacterial endocarditis, rheumatic fever, and a type of kidney disease (glomerulonephritis).

To prepare for the ASO titer test, you may need to refrain from eating or drinking anything for six hours before the test. Your doctor may also recommend that you stop taking certain medications before this test, as corticosteroids and certain antibiotics may reduce ASO antibody levels, making it difficult to confirm your diagnosis.

The risks of the ASO test are minimal. You may experience some pain during or after the blood draw. Other possible risks include difficulty obtaining a sample, excessive bleeding at the needle site, fainting, and infection at the puncture site.

Viral/bacterial testing

• Strep throat culture: This test is used to detect the presence of Streptococcus bacteria in the throat, which is a common trigger for PANDAS. A throat swab is a simple and non-invasive way to collect a sample for testing.
• Antistreptolysin O (ASO): This test detects antibodies produced by the body in response to a Streptococcus infection.
• Lyme disease and co-infections: Lyme disease is caused by the Borrelia burgdorferi bacterium transmitted by tick bites. Testing for Lyme disease involves checking for antibodies to this bacterium in the blood.
• Epstein-Barr Virus Panel: This test detects the presence of the Epstein-Barr virus, which causes infectious mononucleosis ("mono").
• Coxsackie A & B Titers: These tests detect antibodies against the Coxsackievirus, which can cause a range of mild to severe illnesses, including respiratory infections and neurological complications.
• Mycoplasma Pneumoniae IgA & IgM: Mycoplasma pneumoniae is a bacterium that causes "walking pneumonia." The IgA and IgM tests detect antibodies produced by the body in response to this infection.
• Pneumococcal Antibody Titers: These tests detect antibodies against the bacterium Streptococcus pneumoniae, which can cause respiratory infections and other illnesses.

It is important to note that the specific tests performed may vary depending on the patient's symptoms, medical history, and the discretion of the healthcare provider. Viral/bacterial testing is just one aspect of the diagnostic process for PANS and PANDAS, which also includes a thorough clinical evaluation, medical history, and laboratory findings.

Clinical observation

PANS (pediatric acute-onset neuropsychiatric syndrome) is a clinical diagnosis given to children who display a dramatic and abrupt onset of neuropsychiatric symptoms, including Obsessive-Compulsive Disorder (OCD) and/or eating disorders. The cause of PANS is often unknown but is thought to be triggered by infections, metabolic disturbances, and other inflammatory reactions. The diagnosis of PANS should be considered when symptoms of OCD, eating restrictions, or tics emerge suddenly and are accompanied by other emotional and behavioural changes, such as anxiety, irritability, and aggression.

Dramatic Onset of OCD or Eating Disorders

Children with PANS often exhibit a rapid and drastic change in their eating habits or the development of OCD tendencies. This can include severe restrictions on food intake, with some children showing observable weight loss. They may also develop new obsessions and compulsions, such as excessive fears of contamination leading to frequent handwashing.

Neuropsychiatric Symptoms

In addition to OCD or eating disorders, children with PANS experience a range of other neuropsychiatric symptoms. These can include anxiety, irritability, uncontrolled emotions, depression, behavioural regression, and sudden deterioration in school performance. They may also exhibit motor or sensory abnormalities, such as changes in handwriting or sensitivity to light and sound.

Onset and Severity of Symptoms

Exclusion of Other Disorders

PANS is a "diagnosis of exclusion", meaning that other known medical and neurological conditions must be ruled out before a PANS diagnosis can be made. This includes ensuring that the symptoms are not better explained by another neurologic or medical disorder. A thorough clinical history and examination are crucial to exclude other potential causes.

Laboratory Findings

While there is no definitive test for PANS, laboratory findings can provide supportive evidence. Blood tests may show signs of inflammation, and strep throat cultures or viral/bacterial testing may be relevant, especially in the case of PANDAS, where a Streptococcal infection is the known trigger.

In summary, clinical observation of PANS involves identifying the abrupt onset of OCD or eating disorders alongside other neuropsychiatric symptoms, assessing the severity and impact on the child, ruling out other potential disorders, and considering relevant laboratory findings to support the diagnosis. Early identification and treatment of PANS are crucial for improving the course of illness and long-term outcomes.

Frequently asked questions