POTS Symptoms After COVID and Lyme Disease

POTS can develop following an infection
COVID-19 and Lyme disease may involve overlapping autonomic symptoms
Dizziness, tachycardia, fatigue, and exercise intolerance are common

Postural orthostatic tachycardia syndrome (POTS) has been reported following COVID-19 and other infections. Symptoms may include a rapid heart rate upon standing, dizziness, fatigue, brain fog, and exercise intolerance.

POTS typically occurs “after viral or bacterial infections, such as Epstein-Barr virus, influenza, and Borrelia burgdorferi infection,” explain Blitshteyn and Whitelaw. It may also be triggered by surgery, pregnancy, or a concussion.¹

The authors evaluated 20 patients at a Dysautonomia Clinic who developed autonomic symptoms following presumed or laboratory-confirmed COVID-19. Evidence of orthostatic intolerance was based on a 10-minute stand test or tilt table test.

Six participants had pre-existing minor autonomic symptoms, such as occasional dizziness, syncope, or palpitations. Four had a remote history of concussion.

However, the authors noted that before COVID-19, none of the patients had chronic orthostatic intolerance, and all were fully functional and employed.

For a broader explanation of the condition, see What exactly is POTS?

What Symptoms Developed After COVID-19?

After the acute COVID-19 illness had resolved, most patients experienced chronic and disabling symptoms, including:

• Fatigue
• Postural tachycardia
• Orthostatic intolerance
• Dizziness
• Exercise intolerance

Less common symptoms included hypersomnolence, panic attacks, loss of smell or taste, headaches, neuropathic pain, hypertension, chest tightness, recurrent fevers, weight loss, diarrhea, and oxygen desaturation.

The authors did not determine whether all of these less common symptoms were directly related to autonomic dysfunction.

Were There Signs of Inflammation or Autoimmunity?

Six patients had mild abnormalities on cardiac or pulmonary testing. Four had elevated markers of autoimmunity and/or inflammation.

These findings led the authors to propose that an autoimmune or inflammatory process might contribute to persistent cardiovascular and neurologic symptoms following COVID-19. However, the underlying mechanisms remain under investigation.

How Were the Patients Treated?

Sixteen of the 20 patients received pharmacologic treatment. Medications included beta blockers, fludrocortisone, midodrine, and ivabradine.

Other medications were prescribed for associated conditions, including headaches, neuropathic pain, and allergic symptoms attributed to mast cell activation disorder.

Did the Patients Recover?

Only three patients with autonomic dysfunction recovered during the follow-up period.

Overall, 85% reported residual symptoms six to eight months after COVID-19, although many felt they had improved with treatment. Eight patients were able to return to work either part-time or full-time.

What Does This Study Show About Lyme Disease and POTS?

This case series evaluated autonomic disorders following COVID-19 and did not directly study patients with Lyme disease. Lyme disease was discussed as one of several infections previously associated with the development of POTS.

A separate case series described two women who developed persistent orthostatic intolerance consistent with POTS following treated Lyme disease. Although this report supports a possible association, larger studies are needed to determine how frequently POTS develops following Lyme disease.²

Patients with Lyme disease and patients recovering from COVID-19 may report overlapping symptoms, including dizziness, palpitations, fatigue, brain fog, and exercise intolerance. These symptoms are not specific to POTS, so an appropriate clinical evaluation is needed to determine whether orthostatic intolerance or another condition is present.

Authors’ Conclusions

• POTS and other autonomic disorders can follow COVID-19 in previously healthy, non-hospitalized patients.
• These disorders may remain significantly disabling six to eight months after the acute infection.
• Mild cardiac, pulmonary, autoimmune, or inflammatory abnormalities were found in some patients.
• Further research is needed to determine whether post-COVID autonomic disorders involve autoimmunity and which antibodies or cytokines might contribute.

Frequently Asked Questions

What are the common symptoms of POTS?

Common symptoms include a rapid heart rate upon standing, dizziness, lightheadedness, palpitations, fatigue, brain fog, weakness, and exercise intolerance. Some patients may experience fainting.

Can COVID-19 trigger POTS?

Yes. POTS and other forms of autonomic dysfunction have been reported following COVID-19, including in people who were not hospitalized during their acute infection.

Can Lyme disease be associated with POTS?

POTS has been reported following bacterial infections, including Borrelia burgdorferi infection. A small case series also described POTS following treated Lyme disease, but larger studies are needed to understand the association.

How is POTS evaluated?

POTS may be evaluated by measuring heart rate and blood pressure while lying down and standing, using a monitored standing test or a tilt table test. Symptoms and other possible medical explanations must also be considered.

Clinical Takeaway

POTS and other autonomic disorders can develop after COVID-19 and have also been reported following infections such as Lyme disease. Persistent dizziness, tachycardia, fatigue, brain fog, or exercise intolerance—particularly when symptoms worsen upon standing—may warrant an evaluation for orthostatic intolerance.

Recognizing an autonomic component may help explain persistent symptoms and guide appropriate supportive treatment.

Related Articles

POTS patients with brain fog have neurocognitive deficits
POTS: An autonomic disorder in Lyme disease patients
Could POTS and Lyme disease impair cognitive function while standing?

References

1. Blitshteyn S, Whitelaw S. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: A case series of 20 patients. Immunol Res. 2021;69(2):205–211. doi:10.1007/s12026-021-09185-5.
2. Noyes AM, Kluger J. A tale of two syndromes: Lyme disease preceding postural orthostatic tachycardia syndrome. Ann Noninvasive Electrocardiol. 2015;20(1):82–86. doi:10.1111/anec.12158.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention