PANDAS in the post-COVID era: links to group A Streptococcus and implications for pediatric neuropsychiatry ‒ a narrative review.

Abstract

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are defined by the abrupt onset of tics and/or obsessive-compulsive symptoms temporally linked to group A Streptococcus (GAS). Post-pandemic reports note a rebound of pediatric invasive GAS (iGAS), providing an epidemiologic backdrop for more frequent neuropsychiatric presentations. This narrative review (2020-2025; PubMed/MEDLINE, ScienceDirect, Wiley Online Library, MDPI, plus snowballing) synthesizes evidence on the PANDAS/PANS-GAS relationship, clinical spectrum, differential diagnosis with Sydenham chorea (SC), immunopathogenesis, and treatment. Beyond classic OCD and motor tics, the phenotype includes speech disfluency, ocular tics, and acute eating restriction with functional and nutritional risk. Immunologic data support molecular mimicry, Th17/IL-17-driven neuroinflammation, blood‒brain barrier dysfunction, and antineuronal or folate receptor-α antibodies; however, no single validated biomarker exists, and antistreptolysin O (ASO), anti-DNase B document exposure only. Management is individualized and multimodal: antibiotic eradication (with prophylaxis in selected, frequently relapsing cases), immunomodulation (steroids, intravenous immunoglobulin (IVIG), therapeutic plasma exchange) for severe/refractory courses, and Cognitive Behavioral Therapy/Selective Serotonin Reuptake Inhibitors (CBT/SSRIs) for core psychiatric symptoms. Contemporary data strengthen a post-streptococcal, immune-mediated framework while underscoring heterogeneous case definitions and the paucity of high-quality trials; prospective biomarker and treatment validation remain priorities.