Case #2
Anxiety disorder, OCD, or something else?

8-year-old black male

 

Decision Point One


 Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)
Decision Point Two
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Refer client to a pediatric neurologist

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • You learn that the pediatric neurologist completed a comprehensive assessment on Tyrel, and although symptoms of OCD seem to have occurred after he was sick, and although antistreptolysin O titers were elevated, there is insufficient evidence for the diagnosis of PANDAS.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Begin Zoloft 75 mg orally daily
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? The PMHNP should consider working in collaboration with the pediatric neurologist to optimize outcomes for this client and his family. Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. In this scenario, Fluvoxamine (immediate release) 25 mg orally daily would be the most appropriate agent.


Begin Fluvoxamine 25 mg orally daily
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? The PMHNP should consider working in collaboration with the pediatric neurologist to optimize outcomes for this client and his family. Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. In this scenario, Fluvoxamine (immediate release) 25 mg orally daily would be the most appropriate agent.


Begin Risperdal 0.5 mg orally twice a day
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? The PMHNP should consider working in collaboration with the pediatric neurologist to optimize outcomes for this client and his family. Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. In this scenario, Fluvoxamine (immediate release) 25 mg orally daily would be the most appropriate agent.


Begin Methylprednisolone 60 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to your office, you learn that Tyrel has had no change in symptoms. His mother reports that his handwashing remains unchanged and that he is still avoiding school.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Increase Methylprednisolone to 60 mg orally twice a day
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? For instance, in this decision, the dose of Methylprednisolone offered is far below what would be considered appropriate if this were PANDAS (Methylprednisolone would be started at around 1000 mg daily ×3 days with a slow taper over the course of several weeks).

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Geodon are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.


Add Geodon 20 mg orally daily to current regimen
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? For instance, in this decision, the dose of Methylprednisolone offered is far below what would be considered appropriate if this were PANDAS (Methylprednisolone would be started at around 1000 mg daily ×3 days with a slow taper over the course of several weeks).

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Geodon are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.


Reconsider diagnosis
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? For instance, in this decision, the dose of Methylprednisolone offered is far below what would be considered appropriate if this were PANDAS (Methylprednisolone would be started at around 1000 mg daily ×3 days with a slow taper over the course of several weeks).

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Geodon are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.


Begin Risperdal 0.5 mg orally twice a day

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to your office, you learn that Tyrel has had no change in symptoms. His mother reports that his handwashing remains unchanged, but he seems more accepting of going to school. Tyrel’s mom is also concerned about how tired Tyrel seems to be since starting the medication.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Change regimen to 1 mg of Risperdal at night to decrease daytime sedation
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? Risperdal is not an approved drug to treat this condition, and this medication would only be used if psychotic symptoms were present. However, an atypical antipsychotic in and of itself would not address the underlying pathophysiology of PANDAS.

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Risperdal or Abilify are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.


Switch to a nonsedating antipsychotic such as Abilify
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? Risperdal is not an approved drug to treat this condition, and this medication would only be used if psychotic symptoms were present. However, an atypical antipsychotic in and of itself would not address the underlying pathophysiology of PANDAS.

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Risperdal or Abilify are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.


Reconsider initial diagnosis
Guidance to Student

If the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? Risperdal is not an approved drug to treat this condition, and this medication would only be used if psychotic symptoms were present. However, an atypical antipsychotic in and of itself would not address the underlying pathophysiology of PANDAS.

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Risperdal or Abilify are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.