PANDAS and Lyme Disease in Children: A Pediatric Case Study
Sudden neuropsychiatric symptoms in children may have infectious triggers
PANDAS, PANS, and Lyme disease can share overlapping symptoms
Careful evaluation may help identify treatable causes
PANDAS and Lyme disease may overlap in children who develop sudden neuropsychiatric symptoms, anxiety, obsessive-compulsive behaviors, cognitive decline, fatigue, sleep disruption, and behavioral regression. Although streptococcal infections are classically associated with PANDAS, researchers have also explored whether Lyme disease and other infections may trigger overlapping neuroinflammatory symptoms in some pediatric patients.
Hello, and welcome to another Inside Lyme Podcast. I am your host Dr. Daniel Cameron. In this podcast, I will be discussing the case of a 7-year-old child who was initially diagnosed with PANDAS and later, Lyme disease.
The article by Cross et al. entitled Case Report: PANDAS and Persistent Lyme Disease with Neuropsychiatric Symptoms: Treatment, Resolution and Recovery was published in Frontiers in Psychiatry.1
The 7-year-old girl developed multiple physical and neuropsychiatric symptoms six months after traveling to a tick-endemic region of the United States. During this period, she was treated for three separate strep infections and was subsequently diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections, or PANDAS.
PANDAS was considered based on classic symptoms, 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.
Additional testing revealed that she was also positive by CDC criteria for Lyme disease. The Lyme EIA and Western blot IgM were positive, with 2 of 3 bands. The Western blot IgG was positive for 3 of 10 bands at IGeneX. Her B. henselae IgG was positive at Quest labs. Her IgG Mycoplasma and IgG Babesia duncani antibodies were positive at IGeneX.
Neuropsychiatric Symptoms in PANDAS and Lyme Disease
Dr. Charles Ray Jones, co-author and treating physician, described the patient’s broad range of symptoms. On 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.”
The patient’s symptoms were extensive and included obsessions, compulsions, ADHD-like behavior, decline in school work, separation anxiety, panic attacks, muscle and joint pain, mood lability, aggressive behavior, fatigue, headaches, difficulty sleeping, word selection problems, cognitive decline, and irrational fears.
Functional Decline in a 7-Year-Old Child
The young girl was considered a gifted child and had excelled academically. But cognitive symptoms 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 explained.
During a ride home with her mother, the patient asked, “Who are you? What’s your name again?” and “I know you are mommy but what’s your name?”
Lyme Disease, PANDAS, and PANS
PANDAS may be diagnosed when a strep infection triggers multiple neurologic and psychiatric symptoms. PANS, or Pediatric Acute-Onset Neuropsychiatric Syndrome, may be triggered by other bacterial, viral, or fungal infections.
Researchers continue to investigate how infections may contribute to neuroinflammation, immune dysregulation, and sudden neuropsychiatric symptoms in susceptible children. Lyme disease, streptococcal infections, Mycoplasma, and other infectious triggers have all been discussed in the broader PANS literature.
Lyme disease, PANS, and PANDAS can present with overlapping symptoms. Dr. Bransfield, a psychiatrist who specializes in tick-borne diseases, has described a broad range of neuropsychiatric symptoms in patients with Lyme disease.2
These symptoms may include anxiety, panic symptoms, intrusive symptoms, depression, sleep disturbance, cognitive impairment, mood changes, behavioral changes, and other neuropsychiatric presentations.
Treatment for PANDAS, Lyme Disease, and Coinfections
According to the authors, the child was treated with multiple courses of oral and IV antibiotics, including intravenous ceftriaxone, Omnicef, Zithromax, Tindamax, Bactrim, and Mepron. Despite this, her symptoms continued, and the Cunningham Panel™ was ordered.
Cunningham Panel™ and IVIG
The Cunningham Panel™ was used by the treating clinicians as part of the broader evaluation for autoimmune-associated neuropsychiatric symptoms. Panel results indicated that the patient had elevated levels for 3 out of 4 autoantibodies: Dopamine D1 Receptor, Dopamine D2L Receptor, and Tubulin.
“Based upon the patient’s Cunningham Panel tests results, the decision was made to prescribe IVIG,” the authors wrote.
Over 31 consecutive months of treatment with various antimicrobials and three courses of IVIG, the patient experienced complete remission and remained symptom-free at the time of publication.
Outcome
“Currently this patient appears to be fully recovered and has been discharged from the care of the pediatric Lyme disease specialist. She is asymptomatic and performing academically at the ‘top’ of her class according to her mother,” the authors wrote.
According to Jones, multiple concomitant infections may be involved and may require treatment to effectively resolve symptoms. Improvement in neuropsychiatric symptoms may not occur unless co-infections are addressed.
Questions Discussed in This Podcast
- What is Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)?
- What are the typical symptoms of PANDAS?
- What are the similarities between Lyme disease, PANS, and PANDAS?
- Why was Lyme disease and other tick-borne illnesses considered?
- Why was the name Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) introduced?
- What is the Cunningham Panel™ and why was it ordered?
- What tests supported the diagnosis of tick-borne illness?
- What neuropsychiatric symptoms did the child experience?
- How was the patient treated for PANS?
- How was the patient treated for Lyme disease, Bartonella, and Babesia duncani?
Frequently Asked Questions
Can Lyme disease mimic PANDAS symptoms?
Lyme disease and PANDAS may share overlapping symptoms, including anxiety, cognitive decline, sleep disruption, behavioral changes, fatigue, headaches, and mood changes.
What is the difference between PANDAS and PANS?
PANDAS is associated with streptococcal infections, while PANS is a broader syndrome in which sudden neuropsychiatric symptoms may follow other infectious or inflammatory triggers.
Can infections trigger sudden neuropsychiatric symptoms in children?
Yes. Infections have been discussed in the PANS literature as potential triggers of sudden-onset obsessive-compulsive symptoms, anxiety, cognitive changes, sleep problems, and behavioral regression in susceptible children.
Why should Lyme disease be considered in some PANDAS or PANS cases?
Lyme disease may be considered when a child has tick exposure, travel to an endemic region, joint pain, fatigue, headaches, neurologic symptoms, or persistent symptoms despite treatment for strep-associated illness.
Is the Cunningham Panel controversial?
The Cunningham Panel™ has been used by some clinicians as part of an autoimmune neuropsychiatric evaluation, but results should be interpreted in clinical context and alongside the broader diagnostic picture.
Clinical Takeaway
PANDAS and Lyme disease in children can be difficult to distinguish when sudden anxiety, obsessive-compulsive symptoms, sleep disruption, fatigue, headaches, cognitive decline, and behavioral changes occur together. This case highlights the importance of considering overlapping infectious and immune-mediated triggers, particularly when symptoms persist despite treatment for presumed strep-associated illness.
Children with abrupt neuropsychiatric decline deserve a careful evaluation that looks beyond a single diagnosis.
Related Articles
These related articles explore pediatric Lyme disease, neurologic symptoms, delayed diagnosis, and overlapping infectious presentations in children.
Pediatric Lyme Disease
Lyme Disease Symptoms Guide
Neurologic Lyme Disease
Lyme Coinfections
Delayed Lyme Disease Diagnosis
References
- Cross A, Bouboulis D, Shimasaki C, Jones CR. Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery. Front Psychiatry. 2021.
- 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
