2026 Poster Presentations
P185: MARKED CLINICAL AND SEROLOGIC IMPROVEMENT AFTER LINGUAL TONSILLECTOMY FOR REFRACTORY PANDAS
Russel T Wagner, BS1; Hannah L Walsh, BS1; Traeton Saint, BS2; George C Bobustuc, MD1; Sammy Khalili, MD1; Miroslav Kovacevic, MD3; Neil S Mundi, MD1; 1Intent Medical Group; 2Edward Via College of Osteopathic Medicine - Louisiana Campus; 3International Child Development Resource Center
Background: Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS) is characterized by abrupt-onset obsessive-compulsive disorder (OCD), tics, and related neuropsychiatric symptoms triggered by Group A Streptococcus (GAS) infections. The pathogenesis is thought to involve post-streptococcal autoimmune mechanisms targeting basal ganglia circuitry. Palatine tonsillectomy and adenoidectomy has been proposed for refractory PANDAS, with some case series reporting symptom improvement. Lingual tonsillectomy has not previously been reported as a treatment for PANDAS.
Case Presentation: We describe a 29-year-old male with adolescent-onset PANDAS, who presented with severe obsessive-compulsive behaviors, coprolalia, emotional lability, and choreiform movements. His symptoms began at age 17 following a streptococcal infection, with episodic exacerbations that closely mirrored spikes in anti-streptolysin O (ASO) titers. He had previously undergone palatine tonsillectomy in childhood for unrelated indications. Despite subsequent immunomodulatory therapy (rituximab and maintenance plasmapheresis) his symptoms remained refractory. On otolaryngologic evaluation, hypertrophied lingual tonsils were identified. He underwent bilateral transoral robotic-assisted lingual tonsillectomy, with histopathology revealing dense lymphoid hyperplasia and reactive germinal centers. Postoperatively, ASO titers normalized over several weeks and the patient experienced marked improvement in compulsive behaviors, tics, and attention.
Conclusion: This case illustrates dramatic clinical and serologic improvement in a refractory PANDAS patient following lingual tonsillectomy. Lingual tonsillar tissue may have served as a persistent immune reservoir in this patient. While palatine tonsillectomy and adenoidectomy have shown benefit in some PANDAS cases, this is the first report involving lingual tonsil resection to our knowledge. Further study is warranted to clarify indications for surgical removal of tonsillar tissues beyond the palatine-adenoid complex in PANDAS.
Figure 1. A) Low-power histology of lingual tonsil demonstrating follicular hyperplasia (*), crypt and adjacent minor salivary gland (H&E stain). B) High-power histology of lingual tonsil showing reactive germinal centers and lymphoid hyperplasia (H&E).
Table 1. Clinical Timeline: ASO Titers and Symptom Status Relative to Lingual Tonsillectomy (Day 0)
Figure 2. Line graph depicting anti-streptolysin O (ASO) titers (IU/mL) over time relative to transoral robotic surgery (TORS) lingual tonsillectomy, performed on Day 0. The patient continued weekly plasmapheresis and immunosuppressive therapy with CellCept throughout the pre- and postoperative period.