Can COVID, Lyme Disease, and Other Infections Trigger POTS?
POTS can develop after infection
COVID-19, EBV, influenza, and Lyme disease may trigger autonomic dysfunction
Symptoms may persist for months after recovery
POTS symptoms have been identified in a group of patients following COVID-19. POTS typically occurs “after viral or bacterial infections, such as Epstein-Barr virus, influenza, and Borrelia burgdorferi infection, [the causative agent of Lyme disease],” explain Blitshteyn and Whitelaw. They also note that POTS can be triggered by surgery, pregnancy, or a concussion.
Post-infectious POTS is increasingly recognized because patients may continue to experience dizziness, rapid heart rate upon standing, fatigue, exercise intolerance, brain fog, palpitations, and other symptoms long after the initial infection has resolved.
Although COVID-19 has brought greater attention to this condition, physicians have described POTS following several infectious illnesses, including Epstein-Barr virus (mononucleosis), influenza, and Lyme disease. These observations suggest that infection may serve as a trigger for autonomic dysfunction in susceptible individuals.
Which infections have been linked to POTS?
POTS has been reported after a variety of viral and bacterial infections. These include COVID-19, Epstein-Barr virus (EBV), influenza, and Borrelia burgdorferi, the bacterium responsible for Lyme disease. Patients commonly develop orthostatic intolerance characterized by dizziness, palpitations, fatigue, exercise intolerance, and cognitive dysfunction.
Researchers believe infection may trigger autonomic dysfunction through immune activation, inflammation, autoimmune mechanisms, small fiber neuropathy, autonomic nerve injury, vascular dysfunction, or impaired cerebral blood flow, although the exact mechanism remains uncertain. Multiple biologic pathways may contribute in susceptible individuals rather than a single cause.
Lyme disease has also been associated with autonomic dysfunction, including POTS-like symptoms in some patients. Individuals may report dizziness, rapid heart rate on standing, fatigue, cognitive difficulties, poor exercise tolerance, gastrointestinal dysmotility, constipation, urinary symptoms, sweating abnormalities, temperature dysregulation, and other manifestations of autonomic dysfunction. These symptoms may overlap with other features of autonomic dysfunction in Lyme disease.
Several published case reports and small case series have described patients who developed postural orthostatic tachycardia syndrome (POTS) following treated Lyme disease, although larger prospective studies are still needed to determine how frequently this occurs and which patients are at greatest risk.
A comprehensive 2024 review concluded that dysautonomia following Lyme disease is biologically plausible because Borrelia burgdorferi can affect the autonomic nervous system during acute infection. The authors also emphasized that current evidence consists primarily of case reports and small case series, and that prospective studies are still needed before dysautonomia can be considered a well-established complication of Lyme disease.
For patients with persistent symptoms after infection, it is important not to assume that fatigue, dizziness, or palpitations are simply part of recovery. A structured evaluation may help identify POTS associated with Lyme disease, post-viral autonomic dysfunction, cardiac or pulmonary abnormalities, or other contributing conditions.
POTS after COVID-19
The patients evaluated at the Dysautonomia Clinic had evidence of orthostatic intolerance (OI) based on either a 10-minute stand test or tilt table test. The study included individuals with presumed COVID-19 rather than restricting enrollment to laboratory-confirmed cases.
READ MORE: What exactly is POTS?
Out of the 20 study participants, six had pre-existing minor autonomic symptoms such as occasional dizziness, syncope, or palpitations, while four had a remote history of concussion.
However, the authors note, “Prior to COVID-19, none had chronic OI, and all patients were fully functional and employed.”
Common symptoms after COVID-related POTS
After recovery from acute COVID-19 infection, “most patients experienced fatigue, postural tachycardia, OI, dizziness, and exercise intolerance that were chronic and disabling.”1
Six patients had mild abnormalities on cardiac or pulmonary testing, while four had elevated markers of autoimmunity and/or inflammation.
Less common symptoms included hypersomnolence, panic attacks, anosmia, ageusia, headaches, neuropathic pain, hypertension, chest tightness, recurrent fevers, weight loss, diarrhea, and oxygen desaturation. The authors did not determine whether these less common symptoms were directly related to autonomic dysfunction.
Many of these complaints overlap with symptoms seen in other post-infectious illnesses, including fatigue, dizziness, cognitive dysfunction, exercise intolerance, and autonomic disorders.
How long can post-viral POTS symptoms last?
Post-viral POTS symptoms may persist for months. In this study, “Most patients (85%) self-reported residual symptoms 6–8 months after COVID-19, although many felt that they had improved with treatment.”1
According to the authors, 16 of the 20 patients (80%) received pharmacologic treatment. Medications included beta blockers, fludrocortisone, midodrine, ivabradine, and additional therapies prescribed for headaches, neuropathic pain, or allergic symptoms associated with mast cell activation disorder.
Only three patients experienced complete recovery from autonomic dysfunction. Eight patients were able to return to work either part-time or full-time.
Some participants had pre-existing autonomic symptoms or a prior concussion, factors that may have contributed to the development of post-COVID autonomic disorders.
Authors Conclude
- “In this largest case series to date, we found that POTS and other common autonomic disorders can follow COVID-19 in previously healthy non-hospitalized patients who experience significant disability 6–8 months after an acute infection.”1
- “… nearly a third of the patients in this case series had confirmed mild abnormalities on cardiac or pulmonary testing, and 20% had abnormal markers of autoimmunity or inflammation, which suggests that patients with persistent cardiovascular and neurologic symptoms after COVID-19 may have an underlying autoimmune and/or inflammatory process that affects cardiopulmonary, neurologic, and immunologic systems.”1
- “Further studies are needed to determine whether post-COVID-19 autonomic disorders are rooted in autoimmunity and what type of antibodies or cytokines may be mediating the autoimmune and/or inflammatory process.”1
Frequently Asked Questions
Can COVID trigger POTS?
Yes. COVID-19 is now recognized as one of the infections that can precede POTS and other forms of autonomic dysfunction. Patients may develop dizziness, rapid heart rate when standing, fatigue, orthostatic intolerance, and exercise intolerance weeks or months after the acute infection.1-3
Can Lyme disease cause POTS symptoms?
Lyme disease has been associated with autonomic dysfunction, including POTS-like symptoms in some patients. Published case reports, small case series, and a recent review suggest a biologically plausible relationship between Lyme disease and dysautonomia, although prospective studies are still needed to determine how frequently this occurs.4,5
Can Epstein-Barr virus (mono) trigger POTS?
Yes. Epstein-Barr virus (the cause of mononucleosis) has been reported as one of several infections that may precede POTS. Patients may develop orthostatic intolerance, fatigue, dizziness, and exercise intolerance following recovery from mono.2,5
Can influenza trigger POTS?
Influenza has also been described as a possible trigger for post-viral POTS. Symptoms may include dizziness, palpitations, fatigue, exercise intolerance, and orthostatic intolerance after the acute illness resolves.2
What are common symptoms of post-infectious POTS?
Common symptoms include rapid heart rate when standing, dizziness, fatigue, brain fog, exercise intolerance, palpitations, headaches, blurred vision, and orthostatic intolerance. Some patients also experience gastrointestinal symptoms, sweating abnormalities, urinary symptoms, and temperature dysregulation.2,5
Clinical Takeaway
POTS can occur after infections, including COVID-19, Epstein-Barr virus, influenza, and Lyme disease. In some individuals, symptoms of orthostatic intolerance, postural tachycardia, dizziness, fatigue, exercise intolerance, and brain fog may persist for months after the initial infection.
Patients with persistent cardiovascular, neurologic, or autonomic symptoms following an infection may benefit from evaluation for POTS, autonomic dysfunction, cardiac or pulmonary abnormalities, inflammatory conditions, and other contributing illnesses.
Recognizing post-infectious POTS may help explain persistent dizziness, rapid heart rate, fatigue, exercise intolerance, and brain fog after COVID-19, Lyme disease, EBV, influenza, and other infections. Current evidence supports an association between Lyme disease and dysautonomia, but larger prospective studies are still needed to determine how frequently Lyme disease contributes to POTS and other autonomic disorders.
Related Articles
Learn more about POTS, autonomic dysfunction, and Lyme disease in these related articles:
- What Exactly Is POTS?
- POTS: An Autonomic Disorder in Lyme Disease Patients
- Could POTS and Lyme Disease Patients Suffer Impaired Cognitive Function When Standing?
- POTS Patients with Brain Fog Have Neurocognitive Deficits
- Autonomic Dysfunction in Lyme Disease
References
- 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.
- Management of POTS due to Long COVID: A Review. Front Neurol. 2022.
- Gunning WT III, Khan S, Spatafore JW, et al. Postural orthostatic tachycardia syndrome in post-COVID-19 long-hauler patients is associated with platelet storage pool deficiency. Front Med (Lausanne). 2025;12:1560120.
- Noyes AM, Kluger J. A Tale of Two Syndromes: Lyme Disease Preceding Postural Orthostatic Tachycardia Syndrome. Ann Noninvasive Electrocardiol. 2015;20(1):82-86.
- Adler BL, Chung T, Rowe PC, Aucott J. Dysautonomia following Lyme disease: a key component of post-treatment Lyme disease syndrome? Front Neurol. 2024;15:1344862. doi:10.3389/fneur.2024.1344862.
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
