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Hi, and welcome! My DS has a similar story to your DD's . . . OCD at age 6, started CBT and some ERP and it backed off for a while, OCD returned with a vengeance at age 8 and this time added low-dose SSRI to therapy which worked for several years, and then at age 12 became so dysfunctional no SSRI worked, wouldn't participate in therapy, etc. That's when we were finally able to get a PANDAs diagnosis and treatment (antibiotics). In our case, because his initial response to antibiotics was so positive, we were able to convince our doctor to continue to renew them, and in the end, he was on them for nearly 2 years, with improvements all along the way. We saw Dr. K. for a consultation and he recommended IVIG for us, also; Dr. K. believes that IVIG is the only true way to "reset" the immune system and stop the autoimmune onslaught behind the anxiety/OCD, and the NIMH (Dr. Swedo) has agreed with him. As you've probably seen here, there are those here who've had positive results with IVIG, and some who've not had palpable or lasting impacts, and I don't think anyone fully understands why the differences. In our case, our DS was responding so well to abx, we decided we'd hold off on IVIG until and unless his improvements ceased or we couldn't get them abx anymore. Not only did the IVIG seem like a more dramatic step, our DS didn't have any immune deficiencies, so we knew our insurance would not cover the treatment. A couple of things you noted I wanted to respond to, specifically: 1) as your DD has had breathing/sinus issues, have you ever had her sinus' "scoped"? There are a couple of families here on the forum who's sinus testing disclosed some cysts in the sinuses that were basically pockets of infection, more or less hanging out there and driving an unrelenting immune response which also reached the brain. Upon having the cysts removed, followed by a round of antibiotics, the child's behavior improved dramatically. We never went to the scoping for our DS, but he, too, had had sinus and breathing issues since he was 2 or 3. We think maybe the long course of abx was necessary in his case because of some infection hanging out in those sinuses that took a while to eliminate non-surgically, as his breathing and sinus issues improved along with his behavior symptoms, and he's not had any significant issues since PANDAs treatment. 2) You mention seeking Lyme testing. I would encourage you to address that before you decide upon IVIG as there have been some reports here by families that IVIG was ineffective or even problematic for them because their child had underlying Lyme and/or co-infections that they didn't know about before moving forward with IVIG. 3) While I do believe that you need to find appropriate medical treatment and perhaps SSRIs will not ever be a successful piece of your DD's health, my DS has continued to benefit from a low-dose SSRI for some occasional, lingering anxiety periods, and there have been other kids here for whom low-dose SSRI's have been helpful in conjunction with other tools. You might consider some genetic testing such as Genomind which focuses on genetic makeup and which psychiatric medications are likely to be effective or not based on one's genetics. And 3), you have a concern about "irreversible brain damage." As the parent of a kid who, like yours, went for many years unsuccessfully treated for an autoimmune response (strep was our culprit), I will tell you that I don't see any brain "damage," per se, but I do believe that my DS's "wiring" today was informed by his experiences all those years. He is now a healthy and happy 20-year-old, a scholarship student living away at college and growing mentally and emotionally on a daily basis. But he is still prone to some anxiety during stressful times, and his go-to response to that anxiety are some OCD behaviors. At this time, the anxiety and OCD are under control and so minor/sub-clinical that if you didn't know him extremely well, you'd have no idea. So, "damage"? I don't think so. But a part of who he is? Maybe. Perhaps he'll continue to mature and evolve past even these remaining behaviors as his mind and body health stay with him. Or he might always have these "tendencies" which, in addition to making him anxious at times, also make him conscientious, sensitive and empathetic toward others and their eccentricities. Hang in there, and all the best! All is NOT lost!

Skin picking, trichotillomania, is indeed a common type of compulsion/OCD. Even if it's a tic, tics are likewise symptoms of PANS/PANDAS.

Antibiotic for the sinus rinse - our ENT chose cleocin gel 1%. It comes in a tube. I suppose the gel is a better choice than trying to do it with a capsule. Cleocin is clindamycin, good for strep. (My kiddo has high strep titers, though I suppose there could be something else in his sinuses like mycoplamsa, in which case clindamycin wouldn't do much, I think.)

-One concern I had with IVIG is the fact it has donor elements and I'm afraid it could transfer a virus or some illness not found to DD. Am I being paranoid about that? Glad to hear it helped your DS! -My DD skin picks as well but Drs said it's just a tic/habit, don't think her's is a compulsion. Thank you very much for your response!

With a history of sinus issues, I will second the recommendation to get that looked at. After three yrs of antibiotics and several months of IVIg (and then a T&A), strep titers still high, we finally got around to a sinus CT. The report did not indicate infection really, but the doc showed me on the CT itself where it looked like there may be infection. We will now be attempting to treat that - not sure what the path will look like except that we are starting off with antibiotic in sinus rinse. I'm hopeful this could be the key we have been missing for so long, infection that oral antibiotics couldn't reach. Or it might be another dead end, but I'll chose hope instead. We found IVIg to be helpful for other symptoms (attention and so forth), just not the OCD. I don't regret the IVIg and I can imagine a situation where we may do more once we are confident we have dealt with the sinuses. I wish we had done the CT earlier as I'm having a "well duh" moment, but it really was not obvious. Mild post-nasal drip is his only symptom. Possible infection in the sinuses fits well with the theory that problematic antibodies cross over into the brain via the olfactory bulb.

What ^^ said. DS17 showed symptoms at around age 8 (hindsight) and we didn't get PANS dx and treatment until age 14. -IVIG: we've had 2 high dose and are trying to get a 3rd approved. Son's immune system is dysregulated and he has hypogammaglobulimia (sp.) among other issues. Resetting his immune system w/IVIG has helped him. Search the boards for IVIG, there are long threads about experiences (I know, in your spare, not, time!). -Long term ABX: we just increased the dose and his current flare calmed down, has been on Augmentin for the entire -OCD: skin picking is very resistent to treatment but once his current flare calmed down a bit, the OCD subsided -Brain damage: don't know b/c he already had an underlying dx of dev.disability (cognitive), from birth. You are not alone!!

Hi Sorry you have not had any replies. We use Seventh Generation products and I make a lot of my own household products with them, along with Greenwise bleach alternative and essential oils. Eliminating chemical products definitely helped with both tics and OCD & general neurology

Interesting. If the Th17 is coming from lymphatic tissue, I suppose it's possible, except that the tonsils are not the only lymphatic tissue in the area and the tonsils aren't the only location for strep infections. There is lymphatic tissue in the sinuses as well as many other areas of the body. This might explain why T&A seems helpful for some cases of PANDAS but nowhere near all. Last I remember, the limited data indicated that T&A helps about half. T&A did not help my kiddo, though I do not regret it. I'm glad we eliminated the possibility. He recently had a sinus CT and we have an appt with ENT soon to discuss the results. Plus, it would be unsurprising to me if my kiddo had strep in the gut, where there is lymphatic tissue, though I don't quite understand how it can really hide there from antibiotics, unlike in the tonsils. Also, our doc frequently mentions that strep can be in the urinary system (bladder) as well.