It starts the moment you stand. Your heart races, your hands tremble, your chest tightens, and your body reacts as if you’ve just run a sprint. Then, when you sit back down, the feeling slowly fades.

For many patients with Lyme disease, this isn’t anxiety or stress. It’s POTS — postural orthostatic tachycardia syndrome — a form of autonomic dysfunction in which the body’s nervous system loses the ability to regulate heart rate, blood pressure, and circulation when changing positions.

What Is POTS?

POTS, or postural orthostatic tachycardia syndrome, affects the autonomic nervous system — the system that regulates heart rate, blood pressure, digestion, and temperature without conscious effort. When you stand, your body should automatically adjust blood flow to your brain.

In POTS, that adjustment falters. The hallmark finding is a heart rate increase of 30 beats per minute or more within 10 minutes of standing, without a corresponding drop in blood pressure. But the experience extends far beyond heart rate — patients describe dizziness, lightheadedness, brain fog, fatigue, and a body that feels stuck in overdrive.

How Lyme Disease Triggers POTS

Lyme disease can inflame or damage the small nerve fibers that regulate automatic body functions. When this system is disrupted, the sympathetic (“fight or flight”) pathway can become locked in high gear.

Several mechanisms connect Lyme disease to POTS:

• Small fiber neuropathy affecting autonomic nerve fibers
• Neuroinflammation disrupting brainstem regulation of heart rate and blood pressure
• Immune-mediated damage to autonomic ganglia
• Post-infectious autonomic imbalance that persists after treatment
• Co-infections such as Babesia and Bartonella compounding autonomic stress

Even after the infection is treated, the nervous system may take time to recalibrate. This doesn’t always mean persistent infection — it can reflect post-infectious autonomic imbalance that improves as the system heals.

Hyperadrenergic POTS in Lyme Disease

Hyperadrenergic POTS is a specific subtype characterized by excessive sympathetic nervous system activity when standing. It is associated with high levels of norepinephrine — a stress hormone — in the blood upon standing.

In hyperadrenergic POTS, the defining feature isn’t always heart rate. It’s the excess release of norepinephrine. The body behaves as though it’s under attack when the patient is simply standing still.

Patients describe trembling hands, a sense of internal vibration, waves of heat that come from nowhere, chest tightness, and a wired feeling that won’t settle. Some feel dizzy or faint; others feel flushed and agitated. Many experience brain fog or headaches, as if the nervous system can’t decide whether to accelerate or slow down.

What Does a POTS Episode Feel Like?

Patients with Lyme disease and POTS often describe a body that overreacts to everyday situations. Standing up to make coffee, walking across a room, or even mild warmth can trigger a rush of adrenaline.

The pattern is familiar: small triggers, big reactions, and a body that won’t settle back down. Heat, dehydration, or stress can magnify symptoms.

Common experiences include:

• Heart racing or pounding upon standing
• Dizziness, lightheadedness, or near-fainting
• Adrenaline surges with trembling and chest tightness
• Exercise intolerance and rapid fatigue
• Exhaustion that worsens with upright activity
• Brain fog, difficulty concentrating, visual changes
• Night sweats and temperature dysregulation
• GI symptoms — nausea, bloating, slowed digestion

POTS and Long COVID: The Same Pattern

POTS is now widely recognized in Long COVID patients — and the overlap with Lyme disease is striking. Both conditions involve post-infectious autonomic dysfunction driven by neuroinflammation and immune dysregulation.

The growing recognition of POTS in Long COVID is helping validate what Lyme patients have experienced for years: that autonomic dysfunction after infection is a documented, physiologic condition — not anxiety.

Why POTS Is Missed in Lyme Disease

POTS is frequently misdiagnosed as anxiety. The adrenaline surges, racing heart, and chest tightness can look like panic attacks to clinicians unfamiliar with autonomic disorders.

Standard cardiac testing — EKGs, echocardiograms, Holter monitors — may appear normal because they are designed to detect structural heart disease, not autonomic dysregulation. A tilt table test or active standing test is often needed to identify POTS, but many patients are never referred for one.

For patients living with Lyme disease and POTS, understanding that these reactions are physiologic, not psychological, often changes everything. It replaces self-doubt with validation.

Supporting Recovery

Recovery from POTS in Lyme disease takes time. As inflammation subsides and the nervous system finds stability, adrenaline surges become less frequent, the heart steadies, and daily life begins to feel more manageable.

Supportive strategies include increased fluid and electrolyte intake to improve blood volume, increased salt intake for patients with low blood pressure, compression garments to reduce blood pooling in the legs, activity pacing to prevent post-exertional crashes, and gradual reconditioning as tolerated.

Addressing the underlying infection and co-infections remains critical. Managing POTS symptoms without treating the infectious trigger often provides only partial relief.

Clinical Takeaway

POTS is a documented, measurable autonomic disorder — not anxiety. When it develops in the context of Lyme disease, it reflects nervous system dysfunction driven by infection, inflammation, and immune activation. Recognizing the connection allows patients and clinicians to move from fragmented symptom management toward a more integrated approach.

Have you been diagnosed with POTS after a tick-borne illness? Share your experience below — your story may help someone else get the right diagnosis.

Frequently Asked Questions

Can Lyme disease cause POTS?
Yes. Lyme disease can inflame or damage the small nerve fibers that regulate autonomic functions. When this system is disrupted, the sympathetic nervous system can become locked in high gear, triggering POTS.

What is hyperadrenergic POTS?
Hyperadrenergic POTS is a subtype characterized by excessive norepinephrine release upon standing. It causes adrenaline surges, trembling, dizziness, and a body stuck in fight-or-flight mode — even without significant heart rate changes.

What does a POTS episode feel like?
Patients describe a rush of adrenaline upon standing — trembling hands, internal vibration, chest tightness, waves of heat, dizziness, and brain fog. Small triggers like standing up or mild warmth can produce intense reactions.

Is POTS from Lyme disease psychological?
No. POTS is a documented, measurable autonomic disorder. The adrenaline surges, heart rate changes, and dizziness are physiologic — not anxiety. Many patients are initially misdiagnosed with anxiety before receiving a correct diagnosis.

Does POTS from Lyme disease improve?
For many patients, yes. As inflammation subsides and the nervous system recalibrates, adrenaline surges become less frequent and daily life begins to normalize. Recovery takes time and often requires addressing the underlying infection.

References

1. Novak P, Felsenstein D, Mao C, et al. Association of small fiber neuropathy and post-treatment Lyme disease syndrome. PLoS One. 2019;14(2):e0212222.
2. Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. J Intern Med. 2019;285(4):352-366.
3. Raj SR. Postural Orthostatic Tachycardia Syndrome. StatPearls. 2023.

Related Reading: POTS and Lyme Disease

POTS

• What Exactly Is POTS — Postural Tachycardia Syndrome?
• POTS: An Autonomic Disorder in Lyme Disease
• POTS and Brain Fog
• POTS Symptoms in COVID-19 Patients
• POTS Similarities in Long COVID and Lyme Disease

Related Conditions

• Autonomic Dysfunction in Lyme Disease
• Lyme Disease Fatigue: Causes, Duration and Recovery
• Brain Fog Lyme Disease: Why It Happens and What Helps
• Lyme Disease Neuropathy: Symptoms and What Causes It
• Lyme Disease Sleep Disorders: Why You Can’t Sleep
• Long COVID and Lyme Disease
• Medical Dismissal and Lyme Disease