PANS and PANDAS in Children: Symptoms, Causes, and Lyme Disease

Sudden neuropsychiatric symptoms deserve medical evaluation
PANS may follow infection or immune activation
The role of Lyme disease remains uncertain

Can Lyme disease trigger PANS in children? Lyme disease can be associated with neuropsychiatric symptoms that resemble PANS, including cognitive problems, irritability, anxiety, sleep disturbance, sensory sensitivity, and obsessive-compulsive symptoms. However, direct evidence that Lyme disease specifically triggers PANS remains limited.

One of the most distressing things a parent can witness is a sudden, unexplained change in their child.

A child who had been functioning normally may abruptly become anxious, obsessive, emotionally unstable, withdrawn, or unusually fearful. They may stop eating, have difficulty sleeping, develop tics or sensory intolerance, experience urinary frequency, or struggle suddenly at school.

Parents sometimes describe the change as occurring almost overnight.

When symptoms develop this abruptly, physicians may consider Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) or, when symptoms are associated with streptococcal infection, PANDAS.

What Are PANS and PANDAS?

PANS stands for Pediatric Acute-Onset Neuropsychiatric Syndrome. It is characterized by the abrupt onset of obsessive-compulsive symptoms or severely restricted food intake together with other acute neuropsychiatric symptoms.

Associated symptoms may include anxiety, emotional instability, irritability or aggression, developmental regression, declining school performance, sensory or motor abnormalities, sleep disturbance, and urinary symptoms.^1,2

PANDAS refers to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. It describes a subgroup in which the neuropsychiatric syndrome is associated with group A streptococcal infection.

PANS is broader. Infection or immune activation has been proposed as a trigger in some patients, but the underlying cause is not known in every child.^2,6

What Symptoms Should Raise Concern for PANS?

The feature that makes PANS particularly striking is the abrupt onset. The change typically develops much more rapidly than would be expected with many common behavioral or psychiatric disorders.

Symptoms may include:

• Sudden obsessive-compulsive thoughts or behaviors
• Severe anxiety or separation anxiety
• Sudden restriction of food intake
• Rage, irritability, or emotional instability
• Motor or vocal tics
• Sensitivity to sound, light, touch, or clothing
• Difficulty concentrating or sudden deterioration in school performance
• Sleep disturbance
• Developmental or behavioral regression
• Frequent urination or new bedwetting

The presence of these symptoms does not by itself identify the cause. A careful evaluation is needed because several infectious, inflammatory, neurologic, metabolic, medication-related, and psychiatric conditions can produce sudden behavioral or neuropsychiatric changes.

Can Lyme Disease Trigger PANS?

This remains an important but unresolved question.

Lyme disease can produce neurologic and neuropsychiatric symptoms. Children with Lyme disease may experience fatigue, headache, cognitive difficulties, irritability, anxiety, sleep problems, sensory symptoms, pain, dizziness, or other neurologic complaints.

Some of these symptoms overlap substantially with those described in PANS.

However, overlapping symptoms do not prove that Lyme disease causes PANS.

The PANS/PANDAS Consortium addressed Lyme disease specifically in its 2017 infection-management guideline. Cooperstock and colleagues noted that obsessive-compulsive symptoms and other neuropsychiatric manifestations have been described in patients with Lyme disease. They also discussed reports of distractibility, declining school performance, irritability, depression, insomnia, and sensitivity to light or sound following Lyme disease.⁵

At the same time, the authors emphasized the weakness of the evidence. They reported that they were unaware of an unequivocal case demonstrating PANS associated with Lyme disease.⁵

That distinction remains important today.

What Does the 2025 American Academy of Pediatrics Report Say?

The American Academy of Pediatrics revisited PANS in a 2025 clinical report.⁶

The AAP recognizes PANS as a likely valid clinical diagnosis but emphasizes that important uncertainties remain regarding its causes, diagnostic biomarkers, and treatment.

Regarding Lyme disease specifically, the report concludes that clear-cut evidence linking Lyme disease directly to PANS has not been established. The AAP therefore does not recommend automatically testing or treating every child with PANS for Lyme disease solely because the child has PANS.⁶

This is an important caution.

A PANS diagnosis by itself is not evidence that a child has Lyme disease.

But that does not mean Lyme disease should never be considered.

When Should Lyme Disease Be Considered in a Child With Sudden Behavioral Changes?

Lyme disease should be evaluated on its own clinical merits.

In my practice, I consider Lyme disease when a child with sudden neuropsychiatric or behavioral symptoms also has a history or clinical picture that independently raises concern for tick-borne illness.

That may include:

• Significant tick exposure or outdoor exposure
• A prior expanding rash or unexplained skin lesion
• New headaches or neurologic symptoms
• Facial weakness
• Migrating musculoskeletal pain
• Unexplained fatigue
• Dizziness or symptoms of autonomic dysfunction
• Sleep disturbance accompanied by other Lyme-compatible symptoms
• A compatible illness developing after potential tick exposure

A remembered tick bite is not required. Many patients never notice the tick that transmitted the infection.

The important point is that Lyme disease should not be diagnosed simply because a child has PANS-like symptoms. Instead, physicians should determine whether the child’s overall history, exposures, examination, and laboratory findings support an independent diagnosis of Lyme disease.

For broader symptom context, see the Lyme Disease Symptoms Guide.

Lyme Disease Can Resemble PANS Without Necessarily Causing PANS

The distinction between a disease causing PANS and a disease producing similar symptoms is easy to overlook.

For example, a child with Lyme disease might develop irritability, cognitive slowing, anxiety, sleep disturbance, sensory intolerance, headaches, fatigue, or declining school performance.

Those symptoms can resemble part of the PANS clinical picture.

But the child may have neurologic or systemic Lyme disease rather than PANS—or may have more than one process occurring at the same time.

This is one reason a diagnostic label should not replace a careful medical evaluation.

What About Tick-Borne Coinfections?

Children with epidemiologic risk for Lyme disease may also have exposure to other tick-borne infections. These infections should be considered when the child’s clinical presentation independently suggests them.

For example, babesiosis may produce fever, chills, sweats, fatigue, weakness, headache, and other systemic symptoms. Anaplasmosis and ehrlichiosis can produce acute febrile illnesses with characteristic clinical and laboratory findings.

However, the presence of PANS symptoms alone is not evidence that a child has Babesia or another tick-borne coinfection.

Testing should be guided by the child’s exposure history, clinical findings, and the characteristics of the suspected infection rather than by the PANS diagnosis alone.

Why Can These Children Be Difficult to Diagnose?

Sudden behavioral symptoms may initially appear psychiatric. A child may be referred for anxiety, OCD, ADHD, depression, a tic disorder, or another behavioral condition before the broader medical history has been fully explored.

Conversely, not every abrupt behavioral change has an infectious explanation.

Potential alternatives can include primary psychiatric disorders, autoimmune encephalitis, seizure disorders, medication effects, thyroid disease, metabolic abnormalities, sleep disorders, toxic exposures, and other neurologic or inflammatory illnesses.

The challenge is to avoid assuming either that the symptoms are entirely psychiatric or that infection must be responsible.

How Is PANS Diagnosed?

PANS remains a clinical diagnosis. There is no single blood test, brain scan, antibody test, or other biomarker that confirms PANS.^2,6

The evaluation begins with a detailed timeline documenting exactly how rapidly the symptoms appeared and which symptoms developed together.

Physicians should then look for evidence of possible infectious, neurologic, inflammatory, metabolic, medication-related, and psychiatric contributors.

Evaluation may include testing for a recent streptococcal infection and other targeted testing when supported by the history and examination.

Lyme disease testing may be appropriate when the patient has a compatible Lyme history or clinical presentation. It should not be ordered automatically simply because PANS has been considered.

How I Approach a Child With Sudden Neuropsychiatric Symptoms

When I evaluate a child with abrupt psychiatric, cognitive, or behavioral symptoms, I first try to determine what changed and when.

I review the child’s prior level of functioning, timing of symptom onset, preceding illnesses, possible tick exposure, outdoor activities, rashes, headaches, musculoskeletal complaints, sleep changes, sensory symptoms, dizziness, heart-rate changes, and other neurologic or systemic symptoms.

I also look for symptoms of autonomic dysfunction, including dizziness, rapid heart rate, temperature intolerance, gastrointestinal symptoms, or difficulty remaining upright.

If the history raises an independent concern for Lyme disease or another tick-borne infection, I evaluate that possibility as part of the broader differential diagnosis.

At the same time, children with severe or rapidly developing neuropsychiatric symptoms often benefit from coordinated care involving their pediatrician and, when appropriate, specialists in neurology, psychiatry, infectious diseases, rheumatology, immunology, or other disciplines.

How Are PANS and PANDAS Treated?

Treatment depends on what is actually found.

The PANS Research Consortium has described a three-part approach that may include treatment of identified infections, management of inflammatory or immune-mediated disease when appropriate, and psychiatric or behavioral support.^3-5

However, recommendations in this field continue to evolve, and there remains disagreement regarding some diagnostic and treatment approaches.

If Lyme disease is independently diagnosed, treatment should address Lyme disease. If streptococcal infection is identified, that infection should be managed appropriately. Other confirmed infections likewise require treatment directed at the specific organism.

Meanwhile, severe anxiety, obsessive-compulsive symptoms, food restriction, sleep disruption, or other disabling psychiatric symptoms should not be ignored while the medical evaluation proceeds.

The goal is not merely to attach the label PANS to a child. The goal is to determine what may be contributing to the sudden deterioration and address each treatable component.

Frequently Asked Questions

Can Lyme disease trigger PANS?

Lyme disease has been proposed as a possible infectious trigger for PANS because Lyme disease can produce neuropsychiatric symptoms that overlap with PANS. However, direct evidence that Lyme disease specifically triggers PANS remains limited. PANS alone should not be considered evidence of Lyme disease.

Can Lyme disease cause sudden behavioral changes in children?

Lyme disease can be associated with neurologic and neuropsychiatric symptoms including irritability, cognitive difficulties, anxiety, sleep disturbance, fatigue, headaches, and sensory symptoms. Sudden behavioral changes have many possible causes, so the complete clinical picture should be evaluated.

Should every child with PANS be tested for Lyme disease?

No. PANS by itself does not establish a reason to diagnose Lyme disease. Lyme testing is more appropriate when the child’s exposure history, accompanying symptoms, examination, or other clinical findings independently raise concern for Lyme disease.

What is the difference between PANS and PANDAS?

PANDAS describes acute-onset neuropsychiatric symptoms associated with group A streptococcal infection. PANS is a broader syndrome characterized by abrupt obsessive-compulsive symptoms or severe food restriction together with other acute neuropsychiatric symptoms.

How is PANS diagnosed?

PANS is a clinical diagnosis. There is currently no single laboratory test or biomarker that confirms it. Diagnosis requires careful assessment of the abrupt symptom onset while evaluating alternative medical, neurologic, infectious, inflammatory, and psychiatric explanations.

Clinical Takeaway

PANS and PANDAS highlight an important clinical lesson: an abrupt and dramatic change in a child’s behavior deserves a careful medical evaluation rather than an assumption about the cause.

Lyme disease can produce neurologic and neuropsychiatric symptoms that overlap with PANS, but current evidence does not establish Lyme disease as a proven cause of PANS.

PANS itself is not evidence of Lyme disease. But when a child with sudden neuropsychiatric symptoms also has a compatible exposure history, systemic symptoms, neurologic findings, or other clinical evidence suggesting Lyme disease, Lyme deserves consideration as part of the broader evaluation.

Related Articles

Learn more about neurologic, cognitive, behavioral, and tick-borne symptoms that may overlap with this presentation.

Lyme Rage: Why Sudden Anger and Outbursts Occur

Babesia Symptoms and Treatment

Lyme Disease Brain Fog: Causes, Symptoms, and Treatment

Lyme Disease Fatigue: Why It Causes Crushing Exhaustion

Autonomic Dysfunction in Lyme Disease: Symptoms, Causes, and Treatment

References

1. Swedo SE, Leckman JF, Rose NR. From Research Subgroup to Clinical Syndrome: Modifying the PANDAS Criteria to Describe PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). Pediatr Ther. 2012;2:113. doi:10.4172/2161-0665.1000113.
2. Chang K, Frankovich J, Cooperstock M, et al. Clinical evaluation of youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): recommendations from the 2013 PANS Consensus Conference. J Child Adolesc Psychopharmacol. 2015;25(1):3-13. doi:10.1089/cap.2014.0084.
3. Thienemann M, Murphy T, Leckman J, et al. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I—Psychiatric and Behavioral Interventions. J Child Adolesc Psychopharmacol. 2017;27(7):566-573. doi:10.1089/cap.2016.0145.
4. Frankovich J, Swedo S, Murphy T, et al. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II—Use of Immunomodulatory Therapies. J Child Adolesc Psychopharmacol. 2017;27(7):574-593. doi:10.1089/cap.2016.0148.
5. Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part III—Treatment and Prevention of Infections. J Child Adolesc Psychopharmacol. 2017;27(7):594-606. doi:10.1089/cap.2016.0151.
6. American Academy of Pediatrics, Board of Directors. Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025;155(3):e2024070334. doi:10.1542/peds.2024-070334.

This article is for educational purposes and is not intended as individual medical advice, diagnosis, or treatment.

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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