PANS-, PANDAS-, and OCD-like Presentations in Children With Lyme Disease

Some children with Lyme disease develop sudden behavioral or psychiatric symptoms that resemble pediatric acute-onset neuropsychiatric syndrome (PANS) or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). These symptoms may include anxiety, obsessive-compulsive behaviors, mood changes, and difficulty concentrating.

Because these presentations involve changes in behavior, emotion, and cognition rather than obvious neurologic deficits, they are sometimes evaluated initially as psychiatric conditions. In certain cases, however, infections or inflammatory processes affecting the nervous system may contribute to these symptoms.

This article is part of the Pediatric Lyme Disease guide, which examines how Lyme disease can affect children differently from adults.

What Are PANS and PANDAS?

Pediatric acute-onset neuropsychiatric syndrome (PANS) describes a condition in which children develop sudden psychiatric or behavioral symptoms, often including obsessive-compulsive behaviors or severe anxiety.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) describe a similar syndrome believed to be triggered by streptococcal infections. In both conditions, the symptoms are thought to involve immune or inflammatory responses affecting brain circuits that regulate behavior and emotion.

A defining feature of these syndromes is the abrupt onset of symptoms, which may appear over days rather than gradually over months.

PANS-, PANDAS-, and OCD-like Presentations

In some children, behavioral or neuropsychiatric symptoms may appear alongside other manifestations of Lyme disease symptoms, including fatigue, headaches, dizziness, or cognitive difficulties.

In these situations, the challenge for clinicians is determining whether the symptoms reflect Lyme disease, another infection, an immune-mediated process, or a combination of factors.

Overlap between Lyme disease and PANDAS-like neuropsychiatric presentations has been discussed in the medical literature, including a review by Rhee and Cameron examining infectious triggers and diagnostic challenges.¹

Common Behavioral Symptoms

Children experiencing PANS-, PANDAS-, or OCD-like symptoms may develop:

• sudden anxiety or panic symptoms
• obsessive thoughts or compulsive behaviors
• irritability or mood swings
• difficulty concentrating
• sleep disturbances
• decline in school performance

These symptoms can be distressing for both children and families and may appear rapidly during the course of illness.

Why These Symptoms Can Be Confusing

Behavioral and neuropsychiatric symptoms in children can have many possible causes. Anxiety disorders, obsessive-compulsive disorder, infections, inflammatory conditions, and neurologic illnesses may all produce overlapping symptoms.

Because Lyme disease can affect the nervous system, some children with tick-borne illness may develop symptoms that resemble psychiatric disorders. This overlap can make diagnosis challenging.

Children with neurologic Lyme disease may also experience symptoms such as headaches, dizziness, fatigue, or autonomic dysfunction. These broader neurologic features are discussed in more detail in Neurologic Lyme Disease in Children.

Other Neuropsychiatric Symptoms

Although this discussion focuses on PANS-, PANDAS-, and OCD-like presentations, children with Lyme disease may experience a broader range of neuropsychiatric symptoms.

• anxiety or panic symptoms
• irritability or mood swings
• attention or concentration difficulties
• sleep disturbances
• cognitive slowing or “brain fog”

Because these symptoms can occur in many pediatric conditions, careful clinical evaluation is necessary to determine the underlying cause.

Possible Infectious Triggers

PANS and PANDAS are most commonly associated with streptococcal infections. However, other infections have been proposed as possible triggers of similar neuropsychiatric symptoms.

Researchers have suggested that inflammatory responses to infections may affect brain regions involved in emotion and behavior. In some children, this process may contribute to sudden changes in mood, anxiety levels, or compulsive behaviors.

Evaluation of Sudden Behavioral Changes

When children develop abrupt behavioral or psychiatric symptoms, clinicians typically consider a wide range of possible causes. Evaluation may include medical history, neurologic examination, laboratory testing, and assessment of possible infectious or inflammatory triggers.

Careful clinical evaluation is essential to determine the underlying cause and guide appropriate management.

Final Thoughts

Some children with Lyme disease may develop behavioral or neuropsychiatric symptoms resembling PANS, PANDAS, or obsessive-compulsive disorder. Recognizing these overlapping presentations can help clinicians and families consider a broader range of possible explanations when children develop sudden behavioral or cognitive changes.

Reference

1. Rhee H, Cameron DJ. Lyme disease and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an overview. International Journal of General Medicine. 2012;5:163–174.