He had a mild SARS-CoV-2 infection, confirmed by PCR, 18 months before we saw him, with a suspected further SARS-CoV-2 infection 6 months later. He had been diagnosed with post-COVID-19 condition (also known as long COVID) in a specialist clinic 3 months before we saw him—reporting a 12-month history of disabling and delayed post-exertional exhaustion, disproportionate to the effort made; he also reported muscular pain, sleep disturbance, visual difficulties, sexual dysfunction, and brain fog. The patient had been diagnosed with postural orthostatic tachycardia syndrome (POTS) 2 months before we saw him, by a cardiologist.
Regarding his medical history, he had been diagnosed with irritable bowel syndrome aged 18 years and attention-deficit hyperactivity disorder aged 31 years. He also had joint hypermobility—he scored 7 out of 9 on the Beighton Score after being assessed by a rheumatologist at age 32 years. He reported pelvic pain since the age of 21 years. He was prescribed sertraline and an oral solution of amitriptyline.
On examination when lying down, his pulse was 68 beats per min and blood pressure was 138/85 mm Hg; on standing for 8 min, his pulse increased to a maximum of 127 beats per min and his blood pressure remained stable at 125/97 mm Hg. He reported accompanying symptoms of feeling foggy and shaky, having tingling, itchiness, and heaviness in his legs: findings consistent with a diagnosis of POTS.
Laboratory investigations showed normal C-reactive protein concentration, normal erythrocyte sedimentation rate, and negative antinuclear antibodies, anti-neutrophil cytoplasm autoantibody, anti-cyclic citrullinated peptide antibodies, and normal immunoglobulin levels.
Considering the patient's signs and symptoms, we diagnosed dysautonomia secondary to SARS-CoV-2 infection and associated with long COVID. We explained that the leg discolouration was due to venous pooling and cutaneous ischaemia; we recommended he increase his fluid intake, increase his salt intake, and do muscle strengthening exercises.
Dysautonomia is a diverse group of disorders affecting either the central or peripheral autonomic nervous system or both. Dysautonomia can be primary, due to a disease of the autonomic nervous system, or secondary, due to a disease that causes secondary damage to the autonomic nervous system.
POTS is a dysautonomia syndrome where patients have orthostatic intolerance with an excessive increase in heart rate and symptoms of light-headedness, non-vertiginous dizziness, and palpitations when standing, but they maintain their blood pressure. They may also report low energy, headache, cognitive impairment, muscle fatigue, chest pain, non-specific weakness, and gastrointestinal symptoms. Onset of POTS may be precipitated by a viral infection, physical trauma, menarche, pregnancy, or surgery; it may co-occur with other conditions, including migraine, hypermobile Ehlers-Danlos syndrome, and chronic fatigue syndrome.
Long COVID is a multisystem syndrome with an array of symptoms and disabilities in daily activities; evidence is growing of a link between long COVID and POTS dysautonomia. In children with long COVID, Bier anaemic spots—not obvious in our patient—and cyanosis with urticarial-like eruption (known as BASCULE) syndrome has been reported.
Contributors
We both provided care for the patient. NI wrote the original draft. We both reviewed and edited the paper. Written consent for publication was obtained from the patient, who also reviewed the final draft.
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