Covid-19 is known to have protean manifestations. But, even almost one and half year later since the pandemic was first recognised, the virus continues to unravel itself every day to reveal some new aspects of the disease.

A small case series from Italy has suggested that children who present with pediatric acute-onset neuropsychiatric syndrome (PANS) may have COVID-19 as the underlying cause. The case series published in The Lancet Child and Adolescent Health has described the cases of two adolescent boys, who developed PANS two weeks after testing positive for COVID-19 with a nasopharyngeal swab test.

• The first patient, a 12-year-old boy, presented with sudden onset of psychiatric disturbances. He had no such personal or family history of either neuropsychiatric disturbances or any movement disorders. Two weeks after the positive test, he suddenly became fearful of catching infections and touching handles and developed the urge to repeatedly wash his hands along with anorexia. Examination revealed severe emotional lability and facial motor tics. His tests were negative for Group A streptococci and anti-basal ganglia antibodies, including full autoimmune panel. EEG, ECG and brain MRI showed no abnormal findings. The Childrens Yale-Brown Obsessive-Compulsive Scale score was 22 indicating moderate severe obsessive-compulsive disorder (OCD). At follow up after two months, he continued to have the desire to wash his hands along with selective eating and motor tics. However, he tested negative for COvid-19.
• The second patient, a 13-year-old boy, developed a sudden compulsive disorder. He used only a tablespoon during his meals and before sleeping, he began to arrange his shoes in a particular manner. No such symptoms in the past were reported. Two weeks prior to hospitalization, the boy had symptoms of fever, cough, GI disturbances and skin rash. He tested positive for Covid-19. On examination, he had a facial motor tic, guttural vocal tics, hyperactivity, aggressiveness, irritability, inattentiveness, and lack of appetite. Like the first patient, he too tested negative for Group A streptococci antibodies, full autoimmune panel and viral serology, including normal EEG, ECG and brain MRI. However, the basal ganglia antibodies titer was1:100. Also, the Childrens Yale-Brown Obsessive-Compulsive Scale score was 28, indicating severe OCD. No improvement was seen at one month follow up.

PANS is a disorder that affects children and adolescents and its features include sudden development of neuropsychiatric symptoms such as OCD along with severe lack of appetite or motor dysfunction. An infectious or autoimmune mechanism seems to be in play in its etiology. A pediatric autoimmune neuropsychiatric disorder may also occur following Streptococcal infection (PANDAS). The two cases reported tested negative for anti-streptolysin O (ASO) titer and anti-DNAse B.

Based on their findings, the authors of the study said that since a temporal association between the sudden onset of symptoms and the diagnosis of COVID-19 was observed, it is likely that PANS may have been caused by the SARS-CoV-2 virus. Hence, they suggest that COVID-19 should be considered in the differential diagnosis of PANS.

Source: Pavone P, et al. SARS-CoV-2 related paediatric acute-onset neuropsychiatric syndrome. Lancet Child Adolesc Health. 2021 Jun;5(6):e19-e21. doi: 10.1016/S2352-4642(21)00135-8. Epub 2021 May 4.

Dr Sanjay Kalra,

DM, Bharti Hospital, Karnal, Immediate Past President, Endocrine Society of India