A gifted nine-year-old landed in a psych unit in 48 hours. Strep was the trigger.

A sudden shift

In May 2022, a nine-year-old boy was admitted to a psychiatric unit with an abrupt, severe onset of obsessive-compulsive disorder. Less than 48 hours earlier, he had been a gifted mathematics student and athlete who participated in music lessons and social activities with his younger sister. Now, he was gripped by an unrelenting obsession with suicide, head banging, agitation, and hand tremors.

One month prior to these symptoms, he had been treated for strep throat, followed by a second illness involving nausea, vomiting, and abdominal pain. On admission, his throat cultures were positive for group-A ß-hemolytic Streptococcus pyogenes (GABHS), and his anti-DNase-B titers were elevated at 460 U/mL. He was treated with amoxicillin, sertraline, and clonidine, and discharged after 13 days.

The body's decline

Three weeks later, the boy was re-admitted after multiple attempts to jump off a second-story deck and down the stairs. His titers had climbed further; his ASO was 400 U/mL and his anti-DNase was 838 U/ml. At this point, several psychiatric medications, including sertraline and clonidine, were discontinued due to worsening irritability and suicidal ideation. He was started on fluvoxamine and prophylactic penicillin.

During this hospital course, the child engaged in continuous self-injurious behaviors, including self-choking and punching himself in the face. A neurology consult noted a borderline elevated CaM Kinase II enzyme on a Cunningham panel. Despite a normal brain MRI, the diagnosis of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus) began to take shape. Because standard medications were failing, doctors trialed ketamine in the ICU and administered intravenous immunoglobulin (IVIG).

A cycle of decompensation

The following months became a cycle of stabilization and collapse. In September 2022, he experienced another decompensation that required hospitalization. He again tested positive for Strep, and his ASO titer reached a massive 3,200 IU/mL. The Boy was treated with more IVIG and clindamycin. While he briefly improved enough to do homework and have play dates, the decline returned in October with another suicide attempt.

The family faced a mountain of medications. At one point, he was simultaneously taking fluvoxamine, clomipramine, lamotrigine, aripiprazole, and azithromycin, yet he continued to suffer from episodes of intense self-choking. Standard psychiatric treatments like SSRIs and antipsychotics appeared ineffective and often seemed to increase his irritability.

A surgical turn

In November 2022, the boy underwent a tonsillectomy and adenoidectomy. Following the surgery, he showed significant improvement. By January 2023, his parents reported fewer intrusive suicidal thoughts and less urge to self-injure, though he still struggled with concentration and academic regression. He was slowly weaned off his psychiatric medications at his parents' request, as they did not attribute his improvement to the drugs and were concerned they fueled his irritability.

Life after the storm

By February 2024, the boy had been off psychotropic medications for a period of time, though he remained on prophylactic antibiotics. Despite reporting continued severe anxiety and depression on clinical scales, his functional life had returned. He was attending school full-time, playing soccer, and maintaining friendships. He had not been rehospitalized and had no recurrence of self-harming behaviors.

The case serves as a record of a child who met all five diagnostic criteria for PANDAS, where traditional psychiatric management failed to address a condition driven by recurrent streptococcal infections. In the end, his family opted to manage his recovery away from psychiatric drugs, focusing instead on the underlying immune triggers.