The study population consisted of 176 children and adolescents; 124 (70.5%) were male. The mean age at the time of evaluation was 10.6 years (SD: 3.9 years). One hundred forty-one (80.1%) of the subjects were white, 4 (2.3%) were black, 5 (2.8%) were Hispanic, and 26 (14.8%) were of other race/ethnicity. The mean age of onset of Tourette's disorder was 6.1 years (SD: 2.5 years; range: 1–13 years). Comorbid psychiatric diagnoses included OCD (n = 91; 51.7%), attention-deficit/hyperactivity disorder (n = 102; 58%), mood disorders (n = 31; 17.6%), non-OCD anxiety disorders (n = 61; 34.7%), and other disorders (n = 86; 48.9%), including enuresis, language disorder, impulse-control disorder, learning disorders, oppositional defiant disorder, conduct disorder, pervasive developmental disorder, and trichotillomania.
Rates of Community Diagnosis
Of the 176 subjects in our sample, 31 (17.6%) received diagnoses of PANDAS in the community. Nineteen subjects had false-positive diagnoses of PANDAS (ie, did not meet the full criteria described by Swedo et al1
) in the community; those 19 subjects represented 61.3% of the 31 subjects who received PANDAS diagnoses in the community. Notably, the diagnosis was made for some children in the community with OCD and/or tic symptoms who had only a single documented elevation in anti–streptolysin-O titer, which provides no useful information without evidence of acute infection; in some cases, the diagnosis was made without any documented laboratory evidence. Although there may be slight variations in anti–streptolysin-O titer measurements among medical laboratories, a single documented elevation indicates only previous exposure to streptococcal bacteria and is not sufficient for a PANDAS diagnosis unless it is accompanied by evidence of acute infection.
provides a cross-tabulation of subjects with respect to whether the PANDAS diagnosis was received in the community or at the CSC. Subjects were significantly less likely (P < .03) to receive a PANDAS diagnosis at the CSC (19 subjects; 10.8%) than in the community (31 subjects; 17.6%).
Cross-tabulation Between Community and CSC PANDAS Diagnoses
Antibiotic and Immunologic Treatments
Of the 31 subjects with community diagnoses of PANDAS, 27 (87%) were treated with antibiotics for either acute treatment of the index episode or prophylaxis. The duration of treatment ranged from brief courses (1 week) to long-term prophylaxis for up to 4 years. Antibiotics prescribed for these subjects included penicillin, amoxicillin, clarithromycin, erythromycin/sulfisoxazole, amoxicillin/clavulanate, azithromycin, clindamycin, and cefadroxil. Subjects were significantly more likely (P < .0001) to be treated with antibiotics if they received a diagnosis of PANDAS in the community (27 of 31 subjects treated; 87%), compared with those who did not receive a diagnosis of PANDAS in the community (5 of 143 subjects treated; 3.5%).
Of the 27 subjects with community diagnoses of PANDAS who were treated with antibiotics, 22 (82%) were treated without laboratory evidence of an infection. Of those 22 subjects, 17 (77%) were treated with antibiotics for an index episode (ie, short-term antibiotic treatment of 10–30 days). Antibiotic treatment ranged from 1 to 5 courses. Twelve subjects (55%) received prophylactic treatment for up to 4 years. Seven subjects (32%) received both acute and prophylactic treatment.
Twelve subjects in the community were diagnosed as having PANDAS according to strict criteria (true-positive cases); all 12 were treated with antibiotics, but 8 (67%) of 12 were treated without identification of an infection source. Nineteen subjects had unconfirmed diagnoses of PANDAS in the community (false-positive cases); of those subjects, 15 were treated with antibiotics, and 14 (93%) of 15 were treated without laboratory documentation of an infection. There were no significant differences with respect to unwarranted antibiotic treatment in the community between subjects who were diagnosed with PANDAS on the basis of all criteria described by Swedo et al1
(true-positive cases) and subjects who were diagnosed without meeting the full criteria (false-positive cases) (P
Two subjects (7%) were treated with steroids and intravenously administered immunoglobulin for tics. When only data for the 31 subjects who received PANDAS diagnoses in the community were examined, antibiotic and/or immunosuppressant treatment was not statistically significantly associated with tic severity (P > .99), comorbid attention-deficit/hyperactivity disorder (P > .99), comorbid mood disorders (P > .99), comorbid OCD (P = .495), or comorbid anxiety disorders (P = .615).
Conventional Treatment of Tics/OCD
Treatment information was available for all 31 subjects with community diagnoses of PANDAS. Of those 31 subjects, 19 (63.3%) received conventional psychopharmacological treatment for tics/OCD (ie, α-adrenergic agonists or neuroleptic agents for tics and selective serotonin reuptake inhibitors for OCD). When proportions of patients in the false-positive (n = 19) and true-positive (n = 12) PANDAS groups who received conventional treatment were compared, subjects with false-positive diagnoses were less likely to be treated with conventional treatment (42.1%) than were those with true-positive diagnoses (91.67%; P < .008). In contrast, of the 143 subjects without community diagnoses of PANDAS, 83 (58.5%) received conventional psychopharmacological treatment. There was no significant difference in the proportions of subjects with and without community diagnoses of PANDAS who received conventional psychopharmacological treatment (P = .77).