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The possibility of COVID-19 long-haulers experiencing symptoms suggestive of postural orthostatic tachycardia syndrome (POTS) was strengthened by a small case series from Sweden.

Three young patients who were suspected of having COVID-19 in the spring of 2020 were diagnosed with POTS more than 3 months later on the grounds of orthostatic tachycardia and chronic symptoms of orthostatic intolerance after exclusion of competing etiologies, reported a group led by Madeleine Johansson, MD, PhD, of Lund University and Skåne University Hospital in Malmö, Sweden, in a paper .

"Much remains unknown about the specific mechanisms responsible for the in post-COVID-19 patients or how long these symptoms will last, but chronic symptoms are expected in a subset of patients based on this initial clinical experience," Johansson's team said.

"This article from Sweden documents what many autonomic clinics are starting to see, which is an increase in referrals for patients with POTS late post-COVID ... The full impact of long COVID and long COVID POTS is not yet known. With over 117 million patients who have suffered from COVID-19, we may be seeing many similar patients," said Satish Raj, MD, of University of Calgary in Alberta, who was not involved with the study.

It is important for clinicians to recognize that POTS can present as a manifestation of post-acute sequelae of SARS-CoV-2 infection, given that there are many treatment options for POTS and a delay in diagnosis leads to further physical deconditioning and poor quality of life, commented Pam Taub, MD, of UC San Diego Health System in La Jolla, California.

The case series follows the of a POTS-like picture after COVID and lends further support to the syndrome's , commented David Benditt, MD, of University of Minnesota in Minneapolis.

Johansson and colleagues noted that POTS can be precipitated by viral illness or severe infection in 30% to 50% of patients.

The three Swedish patients were two women and one man ranging in age from 28 to 42. All three patients experienced flu-like symptoms. The first tested negative for COVID-19 on a nasopharyngeal swab test but had subsequent borderline results on serology tests for SARS-CoV-2; the second had COVID-19 confirmed early on PCR testing; the third kept testing negative for coronavirus but was nevertheless referred to a tertiary center for post-COVID-19 follow-up.

Symptoms suggestive of POTS included persistent fatigue, headache, palpitations, dizziness, brain fog, or exercise intolerance during recovery from COVID-19. Clinicians performed a mix of the Valsalva maneuver and active standing and head-up tilt tests to diagnose POTS in those three patients.

"As research funders think about how to run surveillance, this report points to the importance of assessing orthostatic vital signs with a stand test. This can be done in any doctor's office, or even in a patient's home with an automatic blood pressure monitor," Raj commented.

Johansson's group reported that POTS treatment included increased fluid intake, compression stockings, ivabradine (Corlanor), and beta-blockers.

At the time of the paper's drafting, all three remained on sick leave and two were still highly symptomatic.

"A principal concern with this paper is whether we should label this as POTS. It is certainly likely a form of autonomic disturbance that needs more study in terms of its prevalence, cause (e.g., antibodies, neurohumoral agents, virus directly etc.) and ultimate prognosis. Labeling these patients as 'POTS' further confuses an already confused landscape," Benditt said.

"In the differential diagnosis of POTS, it is important to consider and exclude other identifiable causes of sinus tachycardia such as dehydration, other infections, hyperthyroidism, cardiac disease, anxiety, anemia, metabolic disorders, chronic fatigue syndrome, or deconditioning," Johansson and colleagues noted.

"In any case, clinical investigation should focus on establishing a more specific diagnosis. We cannot assume that all triggers of a 'POTS-like' picture will have the same outcome or respond to the same treatments. Much work is needed," Benditt added.

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