Working Diagnosis:
Long-COVID complicated by postural orthostatic hypotension (POTS)

Treatment:
He was cleared to return to play at a slower pace. He was instructed to take over the counter salt tablets, to add salt to his electrolyte drinks and to take midodrine 2.5mg as needed.

Outcome:
The patient had attempted his institution's return to play protocol a few times but was still symptomatic following resolution of his acute COVID-19 symptoms. His symptoms of hypotension, tachycardia, chest tightness, and lightheadedness following modrate exercise have persisted for 6 months following an initial positive COVID-19 diagnosis. His symptom of lightheadedness was worse when lying down for recovery. His consultation with cardiology included electrocardiograms, echocardiograms, Holter monitor, and stress tests that did not provide a clear answer for his continued exertional symptoms. The patient began a gradual return to play protocol as tolerated including swimming, recumbent biking, and lower extremity resistance training.

A POTS specialist reported the patient had dysautonomia that may be related to COVID-19. Since that visit, symptoms have significantly improved. Currently the patient is close to full activity. He is in his final year of athletic eligibility and has not yet participated with the team. His mental health is being monitored during counseling sessions with a psychiatrist.

Author's Comments:
As more data and cases become available for review regarding COVID-19 cases in athletes, it is important to gain an understanding of the presentation and duration of complications. The athlete in this case received additional care from two POTS specialists but ultimately had a full recovery within 6 months without significant therapeutic intervention.

Editor's Comments:
COVID-19 has been associated with various neurologic manifestations including autonomic dysfunction. Postural orthostatic tachycardia syndrome (POTS) is one of the most common autonomic disorders whose signs range from postural tachycardia, dizziness, orthostatic intolerance, presyncope, to exercise intolerance. Non-pharmacologic treatments are often useful for patients with autonomic dysfunction. They include increasing fluid and salt intake, the use of waist high compression stockings and abdominal binders, small frequent meals to decrease splanchnic diversion, and slowing changes in postural positioning. To decrease the responsiveness of the autonomic system, beta-adrenergic blockade with agents such as propranolol or HCN channel blockers such as ivabradine can decrease the inappropriate increase in heart rate. Agents such as fludrocortisone and midodrine can increase standing blood pressure to lessen symptoms of orthostasis. Intravenous immune globulins can have immunomodulating actions that neutralize circulating myelin antibodies, down-regulate proinflammatory cytokines, and block the complement cascade, shortening symptom duration related to COVID and other inflammatory causes of POTS.

References:
Goldstein DS. The possible association between COVID-19 and postural tachycardia syndrome. Heart Rhythm. 2021;18(4):508-509.

Dani M, et al. Autonomic dysfunction in 'long COVID': rationale, physiology, and management strategies. Clinical Medicine. 2020;21(1):e63-e67.

Kanjwal K, et al. New-onset Postural Orthostatic Tachycardia Syndrome Following Coronavirus Disease 2019 Infection. J Innov Card Rhythm Manag. 2020;11(11):4302-4304.

Bryarly M, et al. Postural Orthostatic Tachycardia Syndrome: JACC Focus Seminar, JACC. 2019;73(10):1207-1228.

Aagaard P, et al. Early Repolarization in Athletes: A Review. Circulation: Arrhythmia and Electrophysiology. 2016;9(3):e003577.

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 March 30:1-6.

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