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

Published: Frontiers in Psychiatry
Progression and treatment of a 7-year-old female with persistent Lyme disease.
Progression and treatment of a 7-year-old female with persistent Lyme disease.

A previously asymptomatic, healthy 7-year-old girl experienced an abrupt onset of several physical, neurological, and psychiatric symptoms increasing in intensity over a 3-week period. 

Strep pharyngitis was diagnosed by a previous physician on three separate occasions with the first episode occurring 180 days prior to the onset of neuropsychiatric symptoms. 

She was initially treated with amoxicillin with no improvement in symptoms. She was then prescribed a course of clindamycin with a notable improvement in the patient's symptoms.

The patient was referred to a psychiatric department. However, the mother chose to have the child evaluated by a developmental pediatrician who diagnosed her with PANDAS, pediatric autoimmune neuropsychiatric disorders associated with strep infections.

Further testing revealed the young girl was positive for Lyme disease (CDC Western blot).

On her first visit with the pediatric Lyme disease specialist, the patient presented with crying, anxiety, headache, joint pain, decreased cognitive functioning, fatigue, nighttime awakening and an extreme fear of sleeping alone. 

Over the course of her illness, the patient was treated with a range of  medications including IV Rocephin, Omnicef,  Zithromax, Tindamax, Augmentin, and Bactrim.

At her 8-week follow-up visit, the mother reported an overall improvement in her child’s symptoms with no headaches, but increased insomnia and scattered joint sensitivities. 

However, over the following months, the patient experienced a waxing and waning of various symptoms including facial “twitching,” depression, hyperactivity, and oppositional behavior.

Test results were positive for Babesia duncani and the patient was treated with Mepron.

At her 4-month follow-up appointment, the patient’s mother reported that her child was having panic attacks and was “terrified” to sleep alone. She had some residual combativeness, lack of focus, and cognitive interference.

The Cunningham Panel™ was ordered to assess the presence of antineuronal antibodies against specific neuronal receptors. 

The patient's Anti-Dopamine D1 Receptor (DRD1), Anti-Dopamine D2L Receptor (DRD2L), and Anti-Tubulin (TUB) were elevated. Her Anti-Lysoganglioside-GM1 (LYSO-GM1) and Calcium/calmodulin-dependent protein kinase II (CaMKII) were normal. 

Published studies demonstrated that the elevated presence of one or more of these antineuronal antibodies and antibody mediated stimulation of CaMKII was strongly associated with autoimmune neuropsychiatric symptoms such as those present in PANDAS and PANS.

Based upon Cunningham Panel test results, the patient began intravenous immunoglobulin (IVIG) treatment.

A follow-up Cunningham Panel test was performed to assess the post-treatment status of antineuronal antibodies. All 5 assay were within normal range and the clinician determined that no further IVIG treatment was needed.

This patient appears to be fully recovered. She is asymptomatic and performing academically at the “top” of her class according to her mother. 

The author’s concluded, “As evidenced by her recovery and resolution of symptoms, treating both the Lyme infection and streptococcal infection, as well as treating the underlying autoimmune etiology of her neuropsychiatric symptoms resulted in a successful outcome.”

Furthermore, “The presence of elevated antineuronal antibodies identified by the Cunningham Panel™ provided an aid in the diagnosis and in directing immunomodulatory treatment.”

“The post-treatment resolution of these autoantibodies provided pathophysiological support for addressing both the infection(s) and the underlying immune system dysfunction which resulted in a positive medical outcome for this patient.”

Read Translational Psychiatry Article
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B. Robert Mozayeni, MD

Medical and Clinical Advisor

B. Robert Mozayeni MD

Dr. B. Robert Mozayeni was trained in Internal Medicine and Rheumatology at Yale and at NIH. He has had pre- and post-doctoral Fellowships in Molecular Biophysics and Biochemistry at Yale, and also at NIH where he was a Howard Hughes Research Scholar at LMB/DCBD/NCI and later, Senior Staff Fellow at LMMB/NHLBI/NIH. Editorial board of Infectious Diseases – Surveillance, Prevention and Treatment. Past President of the International Lyme and Associated Diseases Society (ILADS).

He is an expert in Translational Medicine, the science and art of advancing medical science safely and efficiently. He is a Fellow of the non-profit Think Lead Innovate Foundation and is a co-founder of the Foundation for the Study of Inflammatory Diseases. He is a Founder of the Foundation for the Study of Inflammatory Diseases to crowd-source medical solutions for complex conditions using existing knowledge, diagnostic methods, and therapies to meet patient needs immediately. He is the Chief Medical Officer of Galaxy Diagnostics, LLC. He is a Board member of the Human-Kind Alliance. Dr. Mozayeni has held admitting privileges (since 1994) on the clinical staff of Suburban Hospital, a member of Johns Hopkins Medicine and an affiliate of the National Institutes of Health Clinical Center.

Safedin Sajo Beqaj, PhD, HCLD, CC (ABB)

Moleculera Labs, Clinical Laboratory Advisor
Medical Database, Inc., President and CEO

Sajo Baqaj, PhD

Dr. Sajo Beqaj is board certified in molecular pathology and genetics and licensed as a Bioanalyst and High Complexity Laboratory Director. He has been practicing as a laboratory director since 2005.

Dr. Beqaj served as a technical director and was part of the initial management team for several well-known laboratories in the clinical lab industry including PathGroup, Nashville, TN; DCL Medical Laboratories, Indianapolis, IN, and Pathology, Inc, Torrance, CA. He is currently serving as off-side CLIA laboratory director for BioCorp Clinical Laboratory, Whittier, CA and Health360 Labs, Garden Grove, CA.

Dr. Beqaj received his Ph.D. in Pathology from Wayne State University Medical School, Detroit, Michigan. He performed his post-doctoral fellowship at Abbott Laboratories from 2001-2003 and with Children’s Hospital and Northwestern University from 2003-2005.

Dr. Beqaj has taught in several academic institutions and has published numerous medical textbook chapters and journal articles. He has served as a principal investigator in clinical trials for several well-known pharmaceutical and diagnostic companies such as Roche HPV Athena, Merck HPV vaccine, BD vaginitis panel, Roche (Vantana) CINtec® Histology clinical trials, and has presented various scientific clinical abstracts and presentations.

He is a member of several medical and scientific associations including the Association of Molecular Pathology, American Association of Clinical Chemistry and the Pan Am Society for Clinical Virology. He has served on a number of clinical laboratory regulatory and scientific committees, and has assisted several laboratories and physicians as a Clinical Laboratory Consultant.