POTS in Lyme Disease: An Autonomic Disorder
POTS in Lyme disease is a form of autonomic dysfunction in which the heart rate rises abnormally when standing. The increase is typically at least 30 beats per minute in adults and 40 beats per minute in children when moving from a recumbent to an upright position.
POTS, or postural orthostatic tachycardia syndrome, is one form of autonomic dysfunction in Lyme disease. A review by Tahir and colleagues in Cureus describes the extensive symptoms and treatment options for this condition.
Many patients with Lyme disease develop symptoms of dysautonomia, including dizziness, palpitations, fatigue, and cognitive difficulty. Recognizing the connection between Lyme disease and autonomic dysfunction is important because these symptoms are often misattributed to anxiety, deconditioning, or unrelated neurologic disorders.
Symptoms of POTS in Lyme Disease
The symptoms of POTS extend far beyond heart rate changes. Tahir describes POTS as an autonomic disorder characterized by a wide range of systemic symptoms.
- Palpitations
- Shortness of breath
- Chest discomfort
- Lightheadedness or dizziness
- Nausea
- Blurred vision
- Chronic fatigue
- Sleep disturbances
- Migraines
- Hypermobility in some patients
- Abdominal pain or irritable bowel symptoms
- Bladder dysfunction
Many patients also experience cognitive symptoms such as slowed thinking, difficulty concentrating, and brain fog in Lyme disease. These symptoms often worsen when standing or during prolonged activity.
The multi-system nature of POTS helps explain why the condition is frequently misdiagnosed. Patients may see multiple specialists for different symptoms without the underlying autonomic disorder being recognized.
Why Lyme Disease Can Cause Dizziness When Standing
Many patients with POTS in Lyme disease experience dizziness or lightheadedness when standing. This occurs because autonomic dysfunction interferes with the body’s ability to regulate heart rate, blood pressure, and circulation when moving to an upright position.
When the autonomic nervous system is impaired, blood may pool in the lower body instead of returning efficiently to the heart and brain. As a result, blood flow to the brain may temporarily decrease, leading to symptoms such as dizziness, blurred vision, fatigue, weakness, or feeling faint.
These symptoms are often described as orthostatic intolerance and are commonly seen in patients with autonomic dysfunction in Lyme disease.
How POTS Develops
POTS has heterogeneous pathophysiology. Tahir describes several contributing mechanisms including excessive sympathetic stimulation, defective peripheral autonomic function, hypovolemia, and autoimmune dysfunction.
In Lyme disease, infection-driven inflammation and immune activation may disrupt the autonomic nervous system. This disruption can interfere with the normal regulation of heart rate, blood pressure, and vascular tone, leading to orthostatic intolerance.
Autonomic dysfunction has also been described in other neurological disorders including cerebrovascular disease, movement disorders, dementia, multiple sclerosis, and peripheral neuropathies. These observations suggest that dysautonomia can emerge when nervous system regulation is disturbed by inflammation or injury.
Treatment of POTS
Treatment of POTS focuses on improving blood volume, stabilizing autonomic function, and reducing excessive heart rate responses when standing.
Non-pharmacologic strategies
- Increasing hydration
- Increasing salt intake
- Wearing compression stockings to reduce venous pooling
- Gradual physical reconditioning when tolerated
These measures are often the foundation of treatment and can significantly improve symptoms in some patients.
Pharmacologic options
- Beta-blockers
- Alpha-agonists such as midodrine, which stimulates peripheral vasoconstriction
- Mineralocorticoids such as fludrocortisone, which promote salt and water retention
- Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs)
Tahir’s review also suggests that ivabradine, an FDA-approved heart failure medication, may reduce heart rate in some POTS patients. However, ivabradine is not FDA-approved specifically for POTS and is used off-label in this context.
In patients with Lyme disease, treatment may also include addressing underlying infection or co-infections that may contribute to autonomic dysfunction.
Clinical Takeaways
POTS in Lyme disease is a multi-system autonomic disorder with heterogeneous pathophysiology including sympathetic overstimulation, hypovolemia, and possible autoimmune mechanisms.
Symptoms often include dizziness, palpitations, fatigue, gastrointestinal complaints, and cognitive dysfunction.
Treatment typically combines non-pharmacologic approaches such as hydration and compression with medications that target heart rate regulation and vascular tone.
POTS is one of several conditions associated with autonomic dysfunction in Lyme disease, which can affect heart rate, blood pressure, digestion, bladder function, and cognitive performance.
Frequently Asked Questions
What is POTS in Lyme disease?
POTS is an autonomic disorder causing heart rate to rise at least 30 beats per minute in adults and 40 beats per minute in children when standing. Infection-related inflammation may contribute to autonomic dysfunction in some Lyme disease patients.
What are the symptoms of POTS?
Symptoms include palpitations, lightheadedness, fatigue, nausea, chest discomfort, blurred vision, migraines, and gastrointestinal problems affecting multiple body systems.
How is POTS in Lyme disease treated?
Treatment combines hydration, increased salt intake, compression stockings, and medications such as beta-blockers, midodrine, fludrocortisone, and sometimes SSRIs or ivabradine.
References
- Tahir F, Bin Arif T, Majid Z, et al. Ivabradine in Postural Orthostatic Tachycardia Syndrome: A Review of the Literature. Cureus. 2020;12(4):e7868.
- Xiong L, Leung TWH. Autonomic dysfunction in neurological disorders. Aging (Albany NY). 2019;11(7):1903-1904.
Do we see resolution of POTS with treatment of Lyme disease or is this damage done?
I often see marked improvements in my practice if the cause is a tick borne illness.
I often see marked improvements in my practice if the cause is a tick borne illness.
Yes. I have a patient with POTS who also has lyles disease which I am treating manually (MLD) to the cervical and occipital lymph vessels which accelerates cerebral spinal fluid exit into nasal mucosa and spinal meninges
Dear Dr. Cameron,
The first diagnosis I received in regards to my maladies was Hashimoto’s Thyroiditis, 1986. Followed by Endometriosis, 2003, CFS 2006, Adnomyosis 2006 (full hysterectomy 06/2006) never recovered. 2012 hospitalized for 10 days, 2.3 Hemoglobin. Received 50 Blood Transfusions, still no diagnosis. 17 Root Canals, all failed. Tonsillectomy 2013. Finally 08/2013 tested for Bb, Western Blot ~ Positive for Lyme Disease. 2013 w/Dr. R. Stricker testing & treatment for Bb pos, Babesia pos, Ehrlichia pos. via IGeneX. Presently still displaying symptoms. Testing w/Internist via Quest Diagnostics. New results as follows: LYME AB SCREEN
View trends Index value >0.90. My Question: Do I or should I request additional testing?? Per Website: If Lyme Disease Antibody Screen is ≥0.90, then Lyme Disease Antibodies (IgG, IgM), Immunoblot will be performed at an additional charge (CPT code(s): 86617 x2). I do not believe an Immunoblot was ordered or performed. Your thoughts? Which direction should I proceed? Should tests be performed through IGeneX? My state is governed by IDSA Rules and Regulations. Thank you, Dr. Cameron, you are a blessing and a hero to so many.
Do we see resolution of POTS with treatment of Lyme disease or is this damage done?
My 12 year old has all of these symptoms but was treated for Lyme disease 3 years ago. Could it be this? Her symptoms are palpitations, dyspnea, chest discomfort, lightheadedness, nausea, blurred vision, chronic fatigue, sleeping abnormalities, migraines, hypermobile joints, abdominal pain. And she’s also getting muscle twitches. Her doctors brush off the Lyme because she was treated but all of her testing is coming back good.
I have patients in my practice who have benefited from retreatment for a tick borne illness. I have had these patients be sure there is not another illness.
I have patients in my practice who are doing well after re-treatment for a tick borne infection despite being previously treated. They often have a number of what initially was thought to be unrelated conditions. Of course, they need to be evaluated for other illnesses.
I have hereditary alpha tryptasemia, and my son was just diagnosed with lyme/ co infection of ebv with a wonderful functional med dr you work with ( Dr G Brown. )I have noted cyanosis on my sons legs , along with the brain fog and fatigue , bp at 90/50 .Would like to take him for valsalva /qsart/ tilt but the local hospital here won’t even recognize the lyme . Do you do autonomic testing or know a Lyme friendly autonomic specialist. I’m not sure where the appropriate place to go for lyme related dysautonomia eval would be . Happy to come to NY. …
I have young patients with tick borne illnesses whose autonomic illness can be quite ill with autonomic issues. Some of them get better with treatment with antibiotics. I have had to treat some of them for autonomic issues at the same time. I do not do a tilt table in my office.
I was recently diagnosed with POTS after being hospitalized being tachicardic (heart rates of 150-160 dropping to 60s/70s in seconds). I have a family cardiac history of my father passing from a heart attack at 53 and mother had a heart attack and triple bipass. I have previous diagnosis of Lyme, babesia, parasites, ebv, bartonella, low hormone levels, heavy metal toxicity and mold. Also previous kidney infection and current bilateral stones. I started a beta blocker metoprolol and had horrible side effects though it worked for improving my heart rate I recently had to stop taking. Do you have any suggestions for medication that has worked well for Lyme patients with pots?
I have Lyme disease patients who have POTS. I do not have any new medications. I have patients whose response to medications for POTS improved when their Lyme disease was treated.
I have chronic Lyme, dysautonomia, lupus, gastroparesis and biliary dyskinesia…I have been living with this a very long time…I have had five bullseye rashes in twenty years time and recently bitten again last summer and symptoms got extremely worse..I’m trying to take supplements because I can’t afford a LLMD right now
What came first? Did Lyme disease cause your dysautonomia?
My son has POTS. EDS. MCAS I have people argue with me that it’s not that it’s JUST LYMES. I beg to differ. Your thoughts??
I have patients who fit more than one diagnostic criteria. They typically see more than one specialists during their evaluation and treatment.