الفهرس 
List of Abbreviations
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Abstract
Streptococcal infection in children is usually benign and self-limited, however, in a small percentage of children, prominent neurologic and/or psychiatric sequelae can occur. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection) is a well-defined syndrome in which tics (motor and/or vocal) and/or OCD consistently exacerbate in temporal correlation to a GABHS infection.
The proposed pathophysiology of PANDAS begins with GABHS infecting a susceptible host. An autoimmune reaction occurs, resulting in production of brain tissue specific antistreptococcal antibodies, which triggers an inflammatory response. The autoantibodies react with basal ganglia proteins, particularly in the caudate nucleus and putamen. Obsessions, compulsions, tics and other neuropsychiatric symptoms, arise from interaction between these antibodies and neurons in the basal ganglia via an unknown mechanism.
Egyptian children suffering from RF (with or without chorea) are susceptible for PANDAS. Incidence of PANDAS is more in resistant chorea patients (33%), with females being more affected. The most common neuropsychiatric manifestations in this subgroup includes OCD associated with ADHD, followed by OCD + tics + ADHD, then tics + ADHD, and finally OCD + tics.
Swedo et al., 1998 proposed five diagnostic criteria:
1. The presence of OCD or a tic disorder or both.
2. Pediatric onset.
3. Episodic course of symptom severity with abrupt onset or dramatic symptom exacerbations.
4. Temporal association with GABHS infection.
5. Association with neurological abnormalities during symptom exacerbations.
In addition to tics and OCD, other neuropsychiatric symptoms, such as anorexia nervosa, attention deficit hyperactivity disorder, acute disseminated encephalomyelitis, autism and separation anxiety disorder, have been suggested as variants of PANDAS, but there is only flimsy evidence, based mainly on the presence of streptococci, on the increase in antistreptococcal antibody titers and on D8/17 positivity (proposed peripheral marker for PANDAS).
To date, there is insufficient scientific evidence to support recommendations for antibiotic prophylaxis in PANDAS.
Cognitive Behavioral Therapy (CBT) and serotonergic drugs have proven efficacy, whether or not the symptomatology is triggered by a GABHS infection. Immunomodulatory interventions; plasma exchange, IVIG or sham IVIG proved to be effective in reducing OCD symptoms when standard treatments (combined pharmacology and CBT) fail and symptoms are severe and disabling. Tonsillectomy is not included as an indication for PANDAS syndrome in the criteria established by the Academy of Otorhinolaryngology and Head and Neck Surgery. Plasmapheresis treatment resulted in significant improvement in both obsessive-compulsive symptoms and tics in adult cases with OCD and tic disorder triggered by streptococcal infections, but not for symptoms which exacerbate after a streptococcal infection.