Management of Pediatric PANS with Positive Lyme Serology

Diagnostic Considerations

The American Academy of Neurology and the Infectious Diseases Society of America recommend against routine testing for Lyme disease in children presenting with developmental, behavioral, or psychiatric disorders, due to low-quality evidence (weak recommendation) 1, 2
The American Academy of Neurology and the Infectious Diseases Society of America strongly recommend against routine testing for Lyme disease in patients with psychiatric illness, due to low-quality evidence (strong recommendation) 1, 2
The guidelines only recommend testing when patients present with specific acute neurologic syndromes, such as meningitis, painful radiculoneuritis, or mononeuropathy multiplex, with epidemiologically plausible tick exposure 1, 2
Serology may remain positive for months or years after successful treatment and cannot be used as a marker of active infection 4

The Infectious Diseases Society of America recommends intravenous ceftriaxone 2g once daily for 14 days for patients with objective CNS involvement, such as meningitis or encephalitis 5, 1, 2
For patients with only peripheral nervous system involvement, such as cranial neuropathy, oral doxycycline 100 mg twice daily for 14 days is recommended 5, 3
For a 14-year-old patient, doxycycline is preferred as first-line therapy, at a dose of 4 mg/kg/day in 2 divided doses, maximum 200 mg/day 3
The American Academy of Pediatrics recommends standard oral antibiotic therapy for presumed early or disseminated Lyme disease, with doxycycline 100 mg twice daily for 14 days, while addressing PANS symptoms through appropriate neuropsychiatric management 3, 4, 1, 2

PANS requires its own specific management, including immunomodulatory therapy, psychiatric medications, and treatment of other potential triggers, such as streptococcal infection 1, 2
Severe neuropsychiatric symptoms should be managed by specialists familiar with PANS, as these symptoms are unlikely to resolve with antibiotics alone if Lyme is not the primary driver 1, 2

The Infectious Diseases Society of America recommends against prolonged or repeated courses of antibiotics beyond standard treatment durations, as multiple studies show no benefit to extended antibiotic therapy for persistent symptoms after standard treatment 6, 7, 3
First-generation cephalosporins, such as cephalexin, are ineffective against B. burgdorferi, and fluoroquinolones, carbapenems, vancomycin, and other non-recommended antibiotics should not be used 3, 5, 3
After standard antibiotic treatment, persistent subjective symptoms without objective findings do not indicate ongoing infection, and some patients may develop fibromyalgia or other post-infectious syndromes that are not antibiotic-responsive 6, 7

Most patients respond promptly to appropriate antibiotic therapy, but patients who are more systemically ill at diagnosis may take longer to respond 3
Close follow-up within 24-48 hours is essential to ensure improvement, as tick-borne diseases can rapidly progress 8
Less than 10% of individuals do not respond to antibiotic therapy, as evidenced by persistent objective clinical manifestations, which is distinct from persistent subjective symptoms 3