Onset of Postural Orthostatic Tachycardia Syndrome (POTS) Following COVID-19 Infection: A Pediatric Case Report

Orthostatic intolerance (OI) is a disorder of the autonomic nervous system characterized by the provocation of symptoms with standing and the improvement in symptoms with recumbency.1 In adolescents, postural orthostatic tachycardia syndrome (POTS), a form of OI, is defined by a sustained heart rate (HR) increment of at least 40 beats/minute (bpm) within 10 minutes of standing or head-up tilt in addition to chronic orthostatic symptoms for at least 3 months duration.2 Typically, a head-up tilt test or a 10-minute standing test is required to establish the diagnosis2; however, there is currently no consensus on the exact type of orthostatic stress test needed to provoke symptoms.3 Common symptoms of POTS include lightheadedness, palpitations, fatigue, and generalized weakness2. Treatment of POTS generally starts with non-pharmacologic measures such as increasing dietary fluid and salt intake, wearing compression garments, and gradually increasing physical activity; in cases where non-pharmacologic management is insufficient, a variety of medications can be tried, including vasoconstrictions, volume expanders, and medicines that control HR.3 POTS is most commonly triggered by viral infections, pregnancy, fever, surgery, or trauma.2 Specifically, Sandroni et al4 have reported that up to 50% of patients with POTS reported a history of infection closely preceding the onset of their POTS symptoms. Thus, it is not surprising that several case reports have recently been published documenting the onset of POTS following COVID-19 infection in adults5-7; in contrast, documented cases of POTS following COVID-19 infection in pediatric patients are scarce. Rowe et al8 describe a case of a 19-year-old male with confirmed COVID-19, who developed orthostatic symptoms within 2 weeks of diagnosis. An orthostatic standing testing revealed a striking 70 bpm increase in HR from supine to standing, consistent with a diagnosis POTS. Interestingly, in a case series of 20 adults who developed POTS and other forms of OI after COVID-19 infection, many reported significant improvement in symptoms upon treatment targeted to POTS, including both non-pharmacologic and pharmacologic therapies.9 This case series highlights the importance of recognizing POTS as a possible complication after COVID-19 infection since the diagnosis can significantly alter treatment and outcome for these patients. We report one of the first documented cases of POTS after COVID-19 infection in a pediatric patient.