Post-COVID-19 Abrupt Onset PANS

COVID-19 could be asymptomatic or might present with several signs and symptoms, like non-productive cough, fever, myalgia, fatigue, malaise and gastrointestinal disturbances. Neurological and psychiatric diseases in cases with a COVID-19 infection are reported as well. ¹ Paediatric acute onset neuropsychiatric syndrome (PANS) presents with an abrupt onset of obsessive-compulsive disorder (OCD) or diminished food intake, and concurrent neuropsychiatric symptoms and motor dysfunction. ² Post-infectious, autoimmune and neuro-inflammatory events are the main mechanisms of PANS. ² Here, we report one child with PANS that started 2 weeks after a positive COVID-19 report.

A 12-year male of urban background presented with 4 months of abrupt onset and continuous progressive course, precipitated after COVID-19 infection. Around 4 months back his father was diagnosed to be COVID-19 positive and within a few days the patient also developed fever, dry cough, sore throat and was tested positive for COVID-19 by RTPCR test. His fever subsided by next 3 days and dry cough improved over 2 weeks with testing negative for COVID-19 on day 12 of onset of fever.

However within a day or 2 of negative report there was a change noted in his behaviour. He started repetition of word, sentence or phrase, up to 6, 8, 12, 18 times; with a feeling of dissatisfaction if not repeated correctly or enough times and was associated with bechaini (discomfort) and difficult to control self. Within one week of the first symptom, patient also started doing repetitive touch/acts. Numbers are chosen without any specific reason or attribute of any misshapen or sin on failure to do so. By the second week, he started taking one to two hours in a bath, feeling that he had to apply soap several times. However, there was no excessive concern regarding any dirt or contamination or repetitive hand washing—consuming up to 10 to 20 litres of water per day, with a fear of getting dehydrated during the day to day activity, with increased frequency of urination even at night and within two months also having repetitive outbursts of abusive words lasting for a few minutes with no alteration in consciousness, responsiveness and no sensory or motor loss with a sudden irresistible desire to utter these offensive words.

There were no h/s/o obsessive and compulsive related disorders, autoimmune and neurological/movement dis- orders. There is a history of Anankastic Personality Disorder and stuttering in the father and the grandmother. He had an uneventful birth and was immunised completely till date. His general physical and systemic examination was found to be within normal limits. On MSE, patient greeted the examiner in return but repeated ‘Namaste’ 8 times, continuously repeating words and phrases, perseveration of speech, increased thought flow, obsessive thinking and impulse, compulsive aggression and repetitive acts (verbal) with Insight of 2/6.

Patient was admitted and evaluated in liaison with medicine and paediatrics departments for polyuria and bedwetting by doing EEG, MRI brain, apart from routine blood profile assessment to rule out any medical and neurological causes for this abrupt onset changes. A provisional impression 6B20.1 OCD as per ICD-11 with a differential of PANS. He was given capsule Fluoxetine 20mg which was built up to 40mg. He scored 33 on CY-BOCS that reduced to 22 after 2weeks of inpatient treatment. There was a significant improvement in controlling repetition, bed wetting and aggression and he was discharged on 40mgs of capsule Fluoxetine.

Discussion

PANS is a disorder affecting children and adolescents, of which the onset is characterised by an abrupt onset of neurological and psychiatric symptoms following infection. ³ No specific diagnostic tool has been recognised for PANS, but an infectious and autoimmune mechanism has been proposed. ³

Murphy et al. (2014) and Chang et al. (2015) gave the working diagnostic criteria of PANS defined as ⁴ :

Acute onset of OCD and/or eating restrictions.

Concurrent onset of symptoms in at least two domains (anxiety; emotional labiality and/or depression; irritability, aggression and/or severely oppositional behaviours; behavioural (developmental) regression; deterioration in school performance; sensory or motor abnormalities; and somatic signs and symptoms, including sleep disturbances, enuresis or urinary urgency/frequency).

The adolescent here reported had sudden onset of OCD symptoms along with deteriorating scholastic performance, irritability and enuresis post viral infection (COVID-19); hence was a clinical diagnosis of new-onset PANS (Paediatric Acute-onset Neuropsychiatric Syndrome).

A descriptive study of 130 children ⁵ with confirmed diagnosis of COVID-19 in Italy, showed neurological symptoms including hypo-reactivity (somnolence) or hyperactivity (excessive crying) 4/130 (3.0%), febrile seizures 2/130 (1.5%), and pain in lower limbs 1/130 (0.7%).

Lin and colleagues ⁶ have proposed some suppositions to it. First, they hypothesised an immediate viral injury to neural cells through olfactory nerves and its extension to the CNS via the cribriform plate. The alternate hypothesis is that SARS-CoV-2 causes vascular endothelial injury through its interaction with angiotensin converting enzyme 2 receptors. The third and final hypothesis is that COVID-19 causes an inflammatory and autoimmune injury. How COVID-19 can beget symptoms of PANS still remains an area of worth exploration.