The Signal

PANDAS causes onset of OCD-like behaviors in children

- Drs. KO AND GLAZIER Eve Glazier, M.D., MBA, is an internist and associate professor of medicine at UCLA Health. Elizabeth Ko, M.D., is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoct­,

Dear Doctors: I was surprised when reading one of your columns about obsessive-compulsive disorder that you didn’t talk about the connection to strep throat. My daughter developed OCD symptoms this way, and I can only wonder how she would be struggling today at 22 without the correct diagnosis and treatment..

Dear Reader: You’re referring to a syndrome known as PANDAS, which is short for pediatric autoimmune neuropsych­iatric disorders associated with streptococ­cus. It was first identified in 1998 and has gradually become recognized as a treatable disorder.

PANDAS is marked by the sudden onset of OCD-like behaviors in children infected with Group A streptococ­cus, or strep. Our column space is limited, and since strep wasn’t a factor in the letter we answered regarding obsessive-compulsive disorder, PANDAS didn’t come up. But it’s an important topic that can be helpful to many parents. We’re grateful to you for introducin­g it into the discussion about obsessive-compulsive disorder, or OCD.

As many readers already know, OCD is a stressful and disruptive cycle of thoughts and behaviors that the affected individual finds difficult, or even impossible, to control. The gradual onset of OCD symptoms, which can arise at any time from preschool through adulthood, has been linked to a variety of factors. These factors include a genetic family history, coping behaviors for stressful life events, managing anxiety and associatio­n with other mental health disorders.

PANDAS, by contrast, always appears in proximity to a strep infection. It also occurs quite suddenly and escalates rapidly. Parents say that children who develop PANDAS change overnight. In addition to physical, vocal and behavioral tics and compulsion­s, children can become moody, irritable, hyperactiv­e or fearful; develop severe anxiety; lose urinary continence; have changes to motor skills; and experience joint pain.

The syndrome is not caused by the strep bacteria itself, but rather by the body’s immune response to the infection. This genus of bacteria is skilled at something known as “molecular mimicry.” That means it can evade the immune system by disguising itself as various tissues within the body. When the immune system eventually does identify the strep, it sometimes attacks not only the invader, but also some of the body’s own tissues. Studies have shown that part of this battle can take place in the tissues of the brain. This is believed to play a role in the neurologic­al and psychiatri­c symptoms of PANDAS.

Although it’s theoretica­lly possible for an adult to develop PANDAS, it’s seen most often in children. Up to onethird of sore throats in children are due to strep, as compared to fewer than 10% in adults. And even among children, PANDAS is considered to be somewhat rare. It is estimated that 1 in 200 children with a strep infection goes on to develop the syndrome.

The best treatment for PANDAS is the use of antibiotic­s to eradicate the strep infection. The good news is that many children respond well and their symptoms gradually resolve. When someone’s doctor isn’t familiar with

PANDAS, referrals are available at the Internatio­nal OCD Foundation (iocdf. org) or the PANDAS Physicians Network (

Bladder cancer more common in men

Dear Doctors: What are the symptoms of bladder cancer? I have a close friend who just got diagnosed with it and has begun treatment. We’re both wondering if there were physical signs that could have let him know that something was wrong.

Dear Reader: Bladder cancer is a common malignancy that causes more than 16,000 deaths each year. It’s the fourth-most-common type of cancer in men, and it has a strong link to smoking. Although it was previously thought that smoking tripled someone’s risk of developing bladder cancer, newer research suggests that up to half of all cases may be connected to tobacco use.

The disease typically begins in the specialize­d cells that form the inner lining of the bladder, which is the stretchy, muscular sac that holds urine before it leaves the body. Known as the urothelial cells, they are found throughout the urinary tract, including the kidneys and the ureters, which are the tubes that connect the bladder to the kidneys. And while it’s possible for cancer to form in urothelial cells in any location, it occurs most often in the bladder.

Once establishe­d, bladder cancer tumors can penetrate into the deeper layers of muscle that make up the bladder. As the disease advances, cancer cells can reach the lymph nodes, move to surroundin­g tissues and spread to other parts of the body.

The most common symptoms of bladder cancer include frequent urination, discomfort while urinating and difficulty in urinating. One of the earliest symptoms is the presence of blood in the urine. This can range from enough blood to affect the color of the urine to amounts that are small enough that they require a urinalysis to detect. Blood in the urine may appear only occasional­ly. Weeks, or even months, can go by during which the urine remains clear.

In its earlier stages, bladder cancer often doesn’t cause pain. It’s possible for a man with prostate issues, which can also affect ease and frequency of urination, to overlook the symptoms of bladder cancer because they are similar. When the cancer becomes more advanced, lower back pain may occur. This is typically present on just one side of the body. Pain in the hips or pelvis is also possible.

While bladder cancer is common in men, it is not seen as often in women. In fact, it’s not even in the top 10 cancers that women get. Due to an overlap of symptoms, signs of bladder cancer in women can be mistaken for a urinary tract infection. This can lead to a delay in diagnosis and treatment, and may contribute to the disease being deadlier in women than in men. Another symptom unique to women is postmenopa­usal uterine bleeding. Just as with blood in the urine, this should not be ignored.

Someone experienci­ng the symptoms of bladder cancer should see their doctor. Depending on the stage, treatment includes surgery, chemothera­py, radiation therapy and targeted immunother­apy. When it is caught and treated early, bladder cancer has a very good survival rate.

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