Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- acute-onset (<72 hours) obsessive-compulsive disorder (OCD)
- acute-onset (<72 hours) severely restricted food intake
- acute-onset (<72 hours) concurrent neuropsychiatric symptoms
- relapsing-remitting course
Other diagnostic factors
- current or past group A streptococcus (GAS) infection
- motor signs associated with basal ganglia dysfunction
- sinusitis, otitis media, and other sinopulmonary infections
- systemic inflammation/immune dysregulation
- enuresis
- frequent urination
- sleep disturbances
- dehydration
- palatal petechiae
- low body mass index (BMI)
- vital sign instability
Risk factors
- pre-pubescent onset
- family history of psychiatric disorder
- family history of autoimmunity
- history of developmental disorder
- immune dysfunction
- male sex
- history of infection
Diagnostic investigations
1st investigations to order
- clinical diagnosis
- throat culture for group A streptococcus (GAS)
- polymerase chain reaction (PCR) for group A streptococcus (GAS)
- rapid antigen detection test (RADT) for group A streptococcus (GAS)
- anti-streptococcal serology
- FBC with differential
- C-reactive protein (CRP)
- erythrocyte sedimentation rate (ESR)
- comprehensive metabolic panel
- antinuclear antibodies (ANA)
- immunoglobulins (IgG, IgA, IgM, IgE) with IgG subclasses
- ferritin (iron) and transferrin saturation
Investigations to consider
- urinalysis
- brain MRI
- electroencephalogram (EEG)
- lumbar puncture
- polysomnogram
- musculoskeletal imaging (MRI or ultrasound)
- swallowing studies
Treatment algorithm
new-onset or new flare: mild impairment
new-onset or new flare: moderate to severe impairment
new-onset or new flare: extreme or life-threatening impairment
chronic symptoms
Contributors
Authors
Jennifer Frankovich, MD, MS
Professor Pediatrics - Allergy, Immunology, Rheumatology
Co-Director, Stanford Children’s Immune Behavioral Health Clinic
Director, Stanford Immune Behavioral Health Research Program
Stanford University School of Medicine
Stanford
CA
Disclosures
JF declares that she has no competing interests.
Yuhuan Xie, MD
Clinical Assistant Professor
Psychiatry and Behavioral Sciences - Child & Adolescent Psychiatry and Child Development
Stanford University School of Medicine
Stanford
CA
Disclosures
YX declares that she has no competing interests.
Peer reviewers
Juliette C. Madan, MD, MS
Associate Professor Pediatrics, Psychiatry & Epidemiology
Clinical Director of the Children's Environmental Health and Disease Prevention Research Center
Geisel School of Medicine at Dartmouth
Dartmouth Hitchcock Medical Center
Hanover
NH
Disclosures
JCM declares that she has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Pfeiffer HCV, Wickstrom R, Skov L, et al. Clinical guidance for diagnosis and management of suspected pediatric acute-onset neuropsychiatric syndrome in the Nordic countries. Acta Paediatr. 2021 Dec;110(12):3153-60.Full text Abstract
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 Feb;25(1):3-13.Full text Abstract
Cooperstock MS, Swedo SE, Pasternack MS, et al. Clinical management of pediatric acute-onset neuropsychiatric syndrome: part III-treatment and prevention of infections. J Child Adolesc Psychopharmacol. 2017 Sep;27(7):594-606.Full text Abstract
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 Sep;27(7):574-93.Full text Abstract
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 Sep;27(7):566-73.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Obsessive-compulsive disorder (OCD)
- Anorexia nervosa
- Avoidant-restrictive food intake disorder (ARFID)
More DifferentialsGuidelines
- Clinical guidance for diagnosis and management of suspected pediatric acute-onset neuropsychiatric syndrome in the Nordic countries
- Clinical evaluation of youth with pediatric acute-onset neuropsychiatric syndrome (PANS): recommendations from the 2013 PANS Consensus Conference
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