Case Report: PANDAS and Persistent Lyme Disease With Neuropsychiatric Symptoms: Treatment, Resolution, and Recovery

This case report describes the diagnosis and treatment of a pre-pubertal (onset at age 7) Caucasian female with serological evidence of Lyme disease accompanied by multiple neuropsychiatric symptoms 6 months following a vacation in a tick endemic area of the United States. Prior to the diagnosis of Lyme disease, the patient also met the clinical diagnostic criteria for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep), with serological evidence of three distinct episodes of streptococcal pharyngitis. All three episodes of strep occurred during the 6-months interval between suspected Lyme disease exposure and the onset of multiple neuropsychiatric symptoms. Her sometimes incapacitating symptoms followed a relapsing and remitting course that impacted her personal, family, social, and academic domains. Over a span of 31 consecutive months of treatment with various antimicrobials and three courses of intravenous immunoglobulins (IVIg) she experienced complete remission and remains symptom free at the time of this publication. Written permission was obtained from the minor patient's mother allowing the submission and publication of this case study.

Evaluation of the Cunningham Panel™ in pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS): Changes in antineuronal antibody titers parallel changes in patient symptoms

OBJECTIVE

This retrospective study examined whether changes in patient pre- and post-treatment symptoms correlated with changes in anti-neuronal autoantibody titers and the neuronal cell stimulation assay in the Cunningham Panel in patients with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS), and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS).

METHODS

In an analysis of all tests consecutively performed in Moleculera Labs' clinical laboratory from April 22, 2013 to December 31, 2016, we identified 206 patients who were prescribed at least one panel prior to and following treatment, and who met the PANDAS/PANS diagnostic criteria. Patient follow-up was performed to collect symptoms and treatment or medical intervention. Of the 206 patients, 58 met the inclusion criteria of providing informed consent/assent and documented pre- and post-treatment symptoms. Clinician and parent-reported symptoms after treatment or medical intervention were categorized as "Improved/Resolved" (n = 34) or "Not-Improved/Worsened" (n = 24). These were analyzed for any association between changes in clinical status and changes in Cunningham panel test results. Clinical assay performance was also evaluated for reproducibility and reliability.

RESULTS

Comparison of pre- and post-treatment status revealed that the Cunningham Panel results correlated with changes in patient's neuropsychiatric symptoms. Based upon the change in the number of positive tests, the overall accuracy was 86%, the sensitivity and specificity were 88% and 83% respectively, and the Area Under the Curve (AUC) was 93.4%. When evaluated by changes in autoantibody levels, we observed an overall accuracy of 90%, a sensitivity of 88%, a specificity of 92% and an AUC of 95.7%. Assay reproducibility for the calcium/calmodulin-dependent protein kinase II (CaMKII) revealed a correlation coefficient of 0.90 (p < 1.67 × 10^-6) and the ELISA assays demonstrated test-retest reproducibility comparable with other ELISA assays.

CONCLUSION

This study revealed a strong positive association between changes in neuropsychiatric symptoms and changes in the level of anti-neuronal antibodies and antibody-mediated CaMKII human neuronal cell activation. These results suggest there may be clinical utility in monitoring autoantibody levels and stimulatory activity against these five neuronal antigen targets as an aid in the diagnosis and treatment of infection-triggered autoimmune neuropsychiatric disorders. Future prospective studies should examine the feasibility of predicting antimicrobial and immunotherapy responses with the Cunningham Panel.