Can Lyme Disease Trigger PANDAS? A 7-Year-Old Case Report
Neuropsychiatric symptoms following streptococcal infections
Lyme disease and suspected co-infections identified during evaluation
Recovery after antimicrobial treatment and IVIG
Can Lyme disease trigger PANDAS? PANDAS is specifically associated with group A streptococcal infection, and Lyme disease is not considered a cause of PANDAS under its original diagnostic definition. However, Lyme disease and other infections may produce overlapping neuropsychiatric symptoms or be considered among the proposed precipitants of the broader condition known as Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS). This case report describes a 7-year-old girl who was initially diagnosed with PANDAS and was later found to have evidence of Lyme disease and suspected tick-borne co-infections.
This article is adapted from an Inside Lyme Podcast episode in which I discuss the case of a 7-year-old girl initially diagnosed with PANDAS who was later found to have Lyme disease.
The article by Cross and colleagues, entitled Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery, was published in Frontiers in Psychiatry.1
Initial diagnosis of PANDAS
The 7-year-old girl developed multiple physical and neuropsychiatric symptoms approximately six months after traveling to a tick-endemic region of the United States.
During this period, she was treated for three separate streptococcal infections and was subsequently diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, or PANDAS.
PANDAS was considered based on her characteristic symptoms, history of streptococcal infection, positive antistreptolysin O titer, and slightly elevated anti-DNase B titer.
Despite treatment, however, the patient’s symptoms continued to worsen.
Testing for Lyme disease and suspected co-infections
Additional testing found that the child met CDC serologic criteria for Lyme disease. Her Lyme enzyme immunoassay and IgM Western blot were positive, with two of three IgM bands present.
Testing performed through IGeneX found three of 10 IgG Western blot bands. Her Bartonella henselae IgG test was positive through Quest Diagnostics. IgG antibodies to Mycoplasma and Babesia duncani were positive through IGeneX.
Antibody findings do not always establish whether an infection is currently active. Results should always be interpreted together with the patient’s symptoms, exposure history, physical examination, and response to treatment.
This case illustrates why clinicians may consider tick-borne co-infections when a child has persistent or unexplained symptoms. Additional information about evaluating younger patients is available in the pediatric Lyme disease guide.
Extensive neuropsychiatric symptoms
Dr. Charles Ray Jones, a co-author of the report and the treating physician, described the patient’s broad range of symptoms.
At her first visit, “the patient presented with crying, anxiety, headache, joint pain, decreased cognitive functioning, fatigue, nighttime awakening and an extreme fear of sleeping alone.”
Her reported symptoms included:
- Obsessions and compulsions
- ADHD-like behavior
- Declining school performance
- Separation anxiety
- Panic attacks
- Muscle and joint pain
- Mood lability
- Aggressive behavior
- Fatigue
- Headaches
- Difficulty sleeping
- Word-selection problems
- Cognitive decline
- Irrational fears, including refusal to sleep alone
Neuropsychiatric symptoms have been reported in patients with Lyme disease, particularly when the nervous system is involved. However, these manifestations are not specific to Lyme disease and require evaluation for psychiatric, neurologic, autoimmune, metabolic, medication-related, developmental, and infectious causes.
Lyme disease and PANDAS are distinct disorders with different infectious causes, yet they may share important clinical features including cognitive dysfunction, anxiety, mood changes, declining school performance, fatigue, and behavioral symptoms. Because of this overlap, distinguishing between the two conditions can sometimes be challenging, particularly when symptoms persist despite standard therapy.2
More information about nervous system involvement is available in the overview of neurologic Lyme disease.
Loss of previously acquired abilities
The young girl had been considered gifted and had excelled academically. As her illness progressed, however, cognitive and functional problems emerged.
She reportedly told her mother, “Mom, something happened to my brain.”
“The patient regressed from being a year ahead of her class in math, to being unable to add beyond the number 10. She began having trouble comprehending more difficult reading,” the authors wrote.
During a ride home, the patient reportedly asked her mother, “Who are you? What’s your name again?” She then said, “I know you are mommy but what’s your name?”
Such a striking loss of previously acquired abilities warrants a broad medical, neurologic, psychiatric, developmental, autoimmune, and infectious evaluation rather than assuming that a single diagnosis explains every symptom.
Lyme disease, PANDAS and PANS
PANDAS describes a proposed subgroup of children who develop an abrupt onset or worsening of obsessive-compulsive symptoms or tics that is temporally associated with a group A streptococcal infection.
Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) is a broader clinical syndrome. Unlike PANDAS, PANS does not require evidence of a preceding streptococcal infection and may be considered when a child develops abrupt obsessive-compulsive symptoms or severe food restriction accompanied by additional neuropsychiatric symptoms.
Proposed precipitants of PANS discussed in the medical literature include infections, inflammatory processes, and other physiologic stressors. Identifying a preceding infection, however, does not necessarily establish that the infection caused the neuropsychiatric syndrome.3
Lyme disease, PANS, and PANDAS may share symptoms including anxiety, obsessive-compulsive behavior, emotional lability, sleep disturbance, cognitive dysfunction, fatigue, pain, and declining school performance.
Because of this overlap, Lyme disease may be considered during the evaluation of selected children with suspected PANS or PANDAS, particularly when there is compatible tick exposure, neurologic findings, musculoskeletal symptoms, or other features suggestive of tick-borne illness. A positive Lyme disease test should always be interpreted within the patient’s complete clinical picture rather than in isolation.2,3
Antimicrobial treatment
According to the case report, the child received multiple courses of oral and intravenous antimicrobial therapy. The treatments included intravenous ceftriaxone, cefdinir, azithromycin, tinidazole, trimethoprim-sulfamethoxazole, and atovaquone.
The published regimens were individualized for this patient and should not be interpreted as standard treatment recommendations for every child with Lyme disease, PANS, or PANDAS.
The report describes treatment directed at Lyme disease as well as suspected co-infections, including Bartonella and Babesia duncani. Additional information about babesiosis is available in the overview of Babesia symptoms and treatment.
Despite antimicrobial treatment, the patient continued to experience symptoms, and her clinicians ordered the Cunningham Panel.
Cunningham Panel
The Cunningham Panel identified elevated dopamine D1 receptor antibodies, anti-tubulin antibodies, and calcium/calmodulin-dependent protein kinase II (CaMKII) activity.
The authors interpreted these findings as supporting an autoimmune neuropsychiatric process. However, the Cunningham Panel remains controversial. Although it has been used in research and some specialty clinical practices, questions remain regarding its diagnostic accuracy and specificity. Most experts recommend that the panel not be used alone to diagnose PANS, PANDAS, or other autoimmune neurologic disorders. Results should always be interpreted in the context of the patient’s clinical presentation and other diagnostic findings.
Recovery
According to the authors, the child gradually improved following treatment and eventually returned to normal daily activities. She resumed horseback riding, returned to school, and no longer experienced the severe neuropsychiatric symptoms described earlier in her illness.
As with any individual case report, it is impossible to determine which component of therapy contributed most to recovery or whether improvement reflected the combined effects of antimicrobial treatment, IVIG, supportive care, or the natural course of illness.
Frequently Asked Questions
Can Lyme disease trigger PANDAS?
PANDAS is specifically associated with group A streptococcal infection. Lyme disease is not considered a cause of PANDAS under its original diagnostic definition. However, Lyme disease may produce overlapping neuropsychiatric symptoms or be evaluated as a possible contributor in children with the broader syndrome known as PANS.
What is the difference between PANDAS and PANS?
PANDAS requires evidence suggesting a temporal relationship between streptococcal infection and the abrupt onset of obsessive-compulsive symptoms or tics. PANS is a broader clinical syndrome that may follow various proposed infectious or inflammatory precipitants and does not require evidence of streptococcal infection.
Can Lyme disease mimic PANDAS?
Some children with Lyme disease may develop anxiety, obsessive-compulsive symptoms, cognitive changes, mood disturbances, fatigue, headaches, sleep problems, or behavioral changes. Because these symptoms overlap with PANDAS and PANS, clinicians may consider Lyme disease in selected patients based on their clinical history, examination, and risk of tick exposure.
What is the Cunningham Panel?
The Cunningham Panel measures several antibodies and immune markers that have been investigated in patients with autoimmune neuropsychiatric disorders. Although it may provide additional information in selected cases, it should not be used by itself to establish a diagnosis of PANS or PANDAS.
Should every child with suspected PANDAS be tested for Lyme disease?
No. Lyme disease testing should be guided by the child’s clinical presentation, history of possible tick exposure, physical examination, and geographic risk. Routine Lyme testing is not recommended for every child with neuropsychiatric symptoms.
Clinical Takeaway
This case illustrates the diagnostic complexity that can arise when children present with abrupt neuropsychiatric symptoms. Although PANDAS remains specifically associated with streptococcal infection, Lyme disease and other infections may produce overlapping clinical features or be considered during the evaluation of children with suspected PANS.
No single case report can establish that Lyme disease triggered this child’s illness or determine which treatment was responsible for her recovery. Instead, the report highlights the importance of maintaining a broad differential diagnosis, interpreting laboratory findings carefully, and individualizing evaluation and treatment for each patient.
Children with persistent neuropsychiatric symptoms deserve a careful evaluation that considers infectious, neurologic, psychiatric, autoimmune, developmental, and other medical causes before attributing all symptoms to a single diagnosis.
Related Articles
Pediatric Lyme disease
Neurologic Lyme disease
Tick-borne co-infections
Babesia symptoms and treatment
References
- Cross J, Shah P, Mankodiya K, et al. Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery. Front Psychiatry. 2021;12:505941.
- Rhee H, Cameron DJ. Lyme disease and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an overview. Int J Gen Med. 2012;5:163-174.
- Swedo SE, Menendez CM, Cunningham MW. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). In: Streptococcus pyogenes: Basic Biology to Clinical Manifestations. 2nd ed. NCBI Bookshelf; 2024.
- Bransfield RC. Suicide and Lyme and associated diseases. Neuropsychiatr Dis Treat. 2017;13:1575-1587.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
