PANDAS and Lyme Disease in Children: A Pediatric Case Study

PANDAS and Lyme disease can produce overlapping neuropsychiatric symptoms in children—making diagnosis challenging when symptoms do not respond to standard treatment.

PANDAS and Lyme disease can produce similar neuropsychiatric symptoms in children. In this case report, a 7-year-old girl developed severe behavioral and cognitive changes after visiting a tick-endemic region.

She was initially diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS), but further evaluation revealed Lyme disease and multiple coinfections.

These challenges are part of the broader discussion of pediatric Lyme disease, where infection, immune responses, and neurologic symptoms may intersect.

Key Point

PANDAS and Lyme disease may produce overlapping neuropsychiatric symptoms in children. When symptoms fail to improve with standard PANDAS treatment, clinicians may consider evaluating for Lyme disease and other tick-borne infections.

Clinical Insight

Children with sudden behavioral or cognitive changes are often diagnosed with PANDAS when recent streptococcal infection is present.

However, overlapping infections—including Lyme disease and tick-borne coinfections—may contribute to similar neuropsychiatric symptoms.

Careful clinical evaluation and exposure history can help guide further investigation.

Why PANDAS and Lyme Disease Can Be Confused

PANDAS and Lyme disease can produce overlapping neuropsychiatric symptoms in children.

Both conditions may present with anxiety, obsessive behaviors, cognitive changes, irritability, sleep disturbances, and school difficulties.

Because these symptoms may appear abruptly, distinguishing between infection-triggered autoimmune syndromes and tick-borne illness can be challenging.

When symptoms fail to improve with standard PANDAS treatment, clinicians may consider whether other infections—including Lyme disease or tick-borne coinfections—could be contributing to the clinical picture.

Some children diagnosed with PANDAS may have underlying Lyme disease or other infections contributing to neuropsychiatric symptoms.

Initial Presentation and PANDAS Diagnosis

The 7-year-old girl developed multiple physical and neuropsychiatric symptoms six months after traveling to a tick-endemic region.

During this period she was treated for three separate streptococcal infections and was subsequently diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS).

PANDAS was considered based on classic symptoms and a history of strep infection, a positive ASO titer, and a slightly elevated DNase B titer.

However, despite treatment, the patient’s symptoms continued to worsen.

The article by Cross and colleagues describing this case was published in Frontiers in Psychiatry.

Lyme Disease and Coinfections Discovered

Additional testing revealed the child was positive by CDC criteria for Lyme disease.

The Lyme EIA and Western blot IgM were positive with two of three bands. The Western blot IgG showed three of ten bands at IGeneX laboratory.

Her Bartonella henselae IgG was positive at Quest laboratories. IgG antibodies for Mycoplasma and Babesia duncani were also positive at IGeneX.

These findings suggested the presence of multiple infections beyond the initial PANDAS diagnosis.

Dramatic Cognitive and Behavioral Decline

The patient presented with crying, anxiety, headache, joint pain, decreased cognitive functioning, fatigue, nighttime awakening, and an extreme fear of sleeping alone.

Her symptoms included obsessions, compulsions, ADHD-like behavior, decline in school performance, separation anxiety, panic attacks, muscle and joint pain, mood lability, aggressive behavior, fatigue, headaches, difficulty sleeping, word-finding problems, and cognitive decline.

She reportedly told her mother, “Mom, something happened to my brain.”

The patient regressed from advanced academic performance to significant cognitive difficulty, including problems with math and reading comprehension.

Understanding PANDAS, PANS, and Lyme Disease

PANDAS may be diagnosed when a streptococcal infection triggers sudden neurologic and psychiatric symptoms.

PANS, or Pediatric Acute-Onset Neuropsychiatric Syndrome, is a broader category that includes cases triggered by infections other than streptococcus.

Researchers have proposed that infections beyond streptococcus—including tick-borne infections—may contribute to PANS-like presentations.

Psychiatrist Dr. Robert Bransfield has described a wide spectrum of neuropsychiatric symptoms reported in Lyme disease.

Cunningham Panel and IVIG Treatment

The child was treated with multiple courses of oral and intravenous antibiotics including ceftriaxone, Omnicef, azithromycin, Tindamax, Bactrim, and Mepron.

Despite treatment, significant symptoms persisted and the Cunningham Panel was ordered to evaluate antineuronal antibodies.

The panel indicated elevated Dopamine D1 receptor, Dopamine D2L receptor, and Tubulin antibodies.

Based on these findings, intravenous immunoglobulin (IVIG) was initiated.

Over 31 months of treatment—including antimicrobial therapy and three courses of IVIG—the patient experienced complete remission.

Complete Recovery Achieved

The patient ultimately recovered and returned to normal academic performance according to her mother.

The authors concluded that multiple infections may have contributed to the patient’s symptoms and that improvement occurred after addressing both infectious and immune-related factors.

Clinical Perspective

This case illustrates how complex neuropsychiatric presentations in children may involve overlapping conditions.

While PANDAS focuses on streptococcal triggers, other infections—including Lyme disease—may contribute to similar symptoms.

When children fail to improve with standard PANDAS treatment, clinicians may consider broader infectious evaluation.

Clinical Takeaway

When children diagnosed with PANDAS fail to improve, clinicians should consider Lyme disease and other infections in the differential diagnosis.

This case highlights the importance of careful clinical evaluation when children develop sudden cognitive or behavioral changes.

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