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Meenakshisundaram C, Moustafa A, Ranabothu M, Maraey A, Grubb B. Impact of COVID-19 infection on baseline autonomic symptoms in patients with preexisting postural tachycardia syndrome and orthostatic intolerance: A retrospective study. Am J Med Sci 2024; 367:323-327. [PMID: 38340983 DOI: 10.1016/j.amjms.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 11/07/2023] [Accepted: 12/06/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) and dysautonomia following a SARS-CoV-2 infection have been recently reported. The underlying mechanism of dysautonomia is not well understood. The impact of this viral illness on the underlying autonomic symptoms has not been studied in patients with a pre-existing POTS diagnosis. Our study aims to report the impact of a COVID-19 infection on patients with preexisting POTS, both during the acute phase of the disease and post-recovery. METHODS Institutional Review Board (IRB) approval was obtained to access charts of the study subjects. All patients with known POTS disease who acquired COVID-19 infection between April 2020 and May 2021 were included. The end point of the study was worsening POTS related symptoms including orthostatic dizziness, palpitation, fatigue and syncope/ presyncope post COVID-19 infection that required escalation of therapy. Basic demographics, details of POTS diagnosis, medications, Additional information regarding COVID 19 infection, duration of illness, need for hospitalization, worsening of POTS symptoms, need for ED visits, the type of persisting symptoms and vaccination status were obtained from the retrospective chart review. RESULTS A total of 41 patients were studied. The alpha-variant was the most common causing SARS-CoV-2 infection. 27% (11 patients) of them had tested positive for COVID- 19 infection more than once. About 38 (92.7%) of them reported having worsening of their baseline POTS symptoms during the active infection phase. About 28 patients (68%) experienced worsening of their dysautonomia symptoms for at least 1-6 months post infection. Nearly 30 patients (73.2%) required additional therapy for their symptom control and improvement. CONCLUSIONS Patients with pre-existing POTS, most experienced a worsening of their baseline autonomic symptoms after suffering the COVID-19 infection which required additional pharmacotherapy for their symptom improvement.
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Affiliation(s)
| | | | - Meghana Ranabothu
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Ahmed Maraey
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH, USA
| | - Blair Grubb
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH, USA
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2
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Pena C, Moustafa A, Mohamed AR, Grubb B. Autoimmunity in Syndromes of Orthostatic Intolerance: An Updated Review. J Pers Med 2024; 14:435. [PMID: 38673062 PMCID: PMC11051445 DOI: 10.3390/jpm14040435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Orthostatic intolerance is a broad term that represents a spectrum of dysautonomic disorders, including postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH), as manifestations of severe autonomic failure. While the etiology of orthostatic intolerance has not yet fully been uncovered, it has been associated with multiple underlying pathological processes, including peripheral neuropathy, altered renin-aldosterone levels, hypovolemia, and autoimmune processes. Studies have implicated adrenergic, cholinergic, and angiotensin II type I autoantibodies in the pathogenesis of orthostatic intolerance. Several case series have demonstrated that immunomodulation therapy resulted in favorable outcomes, improving autonomic symptoms in POTS and OH. In this review, we highlight the contemporary literature detailing the association of autoimmunity with POTS and OH.
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Affiliation(s)
- Clarissa Pena
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Abdelmoniem Moustafa
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
| | - Abdel-Rhman Mohamed
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Blair Grubb
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
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3
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Cui YX, Du JB, Jin HF. Insights into postural orthostatic tachycardia syndrome after COVID-19 in pediatric patients. World J Pediatr 2024; 20:201-207. [PMID: 38363488 DOI: 10.1007/s12519-024-00796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/02/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Ya-Xi Cui
- Department of Pediatrics, Peking University First Hospital, No.1 Xi-an Men Street, West District, Beijing 100034, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, No.1 Xi-an Men Street, West District, Beijing 100034, China.
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing 100191, China.
| | - Hong-Fang Jin
- Department of Pediatrics, Peking University First Hospital, No.1 Xi-an Men Street, West District, Beijing 100034, China.
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4
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Ståhlberg M, Mahdi A, Johansson M, Fedorowski A, Olshansky B. Cardiovascular dysautonomia in postacute sequelae of SARS-CoV-2 infection. J Cardiovasc Electrophysiol 2024; 35:608-617. [PMID: 37877234 DOI: 10.1111/jce.16117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/26/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has led to a worldwide pandemic that continues to transform but will not go away. Cardiovascular dysautonomia in postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection has led to persistent symptoms in a large number of patients. Here, we define the condition and its associated symptoms as well as potential mechanisms responsible. We provide a careful and complete overview of the topic addressing novel studies and a generalized approach to the management of individuals with this complex and potentially debilitating problem. We also discuss future research directions and the important knowledge gaps to be addressed in ongoing and planned studies.
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Affiliation(s)
- Marcus Ståhlberg
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ali Mahdi
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Madeleine Johansson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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5
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Kell DB, Khan MA, Kane B, Lip GYH, Pretorius E. Possible Role of Fibrinaloid Microclots in Postural Orthostatic Tachycardia Syndrome (POTS): Focus on Long COVID. J Pers Med 2024; 14:170. [PMID: 38392604 PMCID: PMC10890060 DOI: 10.3390/jpm14020170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/16/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a common accompaniment of a variety of chronic, inflammatory diseases, including long COVID, as are small, insoluble, 'fibrinaloid' microclots. We here develop the argument, with accompanying evidence, that fibrinaloid microclots, through their ability to block the flow of blood through microcapillaries and thus cause tissue hypoxia, are not simply correlated with but in fact, by preceding it, may be a chief intermediary cause of POTS, in which tachycardia is simply the body's exaggerated 'physiological' response to hypoxia. Similar reasoning accounts for the symptoms bundled under the term 'fatigue'. Amyloids are known to be membrane disruptors, and when their targets are nerve membranes, this can explain neurotoxicity and hence the autonomic nervous system dysfunction that contributes to POTS. Taken together as a system view, we indicate that fibrinaloid microclots can serve to link POTS and fatigue in long COVID in a manner that is at once both mechanistic and explanatory. This has clear implications for the treatment of such diseases.
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Affiliation(s)
- Douglas B Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Building 220, Chemitorvet 200, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
| | - Muhammed Asad Khan
- Directorate of Respiratory Medicine, Manchester University Hospitals, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - Binita Kane
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Manchester University Foundation Trust and School of Biological Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
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McMaster MW, Dey S, Fishkin T, Wang A, Frishman WH, Aronow WS. The Impact of Long COVID-19 on the Cardiovascular System. Cardiol Rev 2024:00045415-990000000-00198. [PMID: 38285646 DOI: 10.1097/crd.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Long coronavirus disease (COVID) is the development or persistence of symptoms after an acute SARS-CoV-2 (COVID-19) infection. Fewer patients are developing acute COVID-19 infections, but patients with long COVID continue to have alarming long-term sequelae. Many cardiac magnetic resonance imaging studies show significant changes in cardiac structure after a COVID-19 infection, suggestive of an increased burden of many cardiovascular diseases, notably myocarditis. The pathophysiology of COVID-19 requires viral binding to angiotensin-converting enzyme 2 protein receptors throughout the body, which are upregulated by inflammation. Consequently, the numerous preexisting conditions that worsen or prolong inflammation enhance this binding and have differing effects on patients based on their unique immune systems. These pathophysiological changes drive long COVID cardiac sequelae such as inappropriate sinus tachycardia, postural orthostatic tachycardia, and other types of orthostatic intolerance. Increased screening for long COVID and low-risk interventions such as exercise regimens could alleviate the suffering endured by patients with long COVID. Many studies such as the Researching COVID to Enhance Recovery Initiative (RECOVER) trials at the National Institutes of Health are exploring potential treatments for long COVID patients.
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Affiliation(s)
- Matthew W McMaster
- From the Departments of Cardiology and Medicine, Westchester Medical Center, Valhalla, NY
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Tackey C, Slepian PM, Clarke H, Mittal N. Post-Viral Pain, Fatigue, and Sleep Disturbance Syndromes: Current Knowledge and Future Directions. Can J Pain 2024; 7:2272999. [PMID: 38239826 PMCID: PMC10795785 DOI: 10.1080/24740527.2023.2272999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/16/2023] [Indexed: 01/22/2024]
Abstract
Background Post-viral pain syndrome, also known as post-viral syndrome, is a complex condition characterized by persistent pain, fatigue, musculoskeletal pain, neuropathic pain, neurocognitive difficulties, and sleep disturbances that can occur after an individual has recovered from a viral infection. Aims This narrative review provides a summary of the sequelae of post-viral syndromes, viral agents that cause it, and the pathophysiology, treatment, and future considerations for research and targeted therapies. Methods Medline, PubMed, and Embase databases were used to search for studies on viruses associated with post-viral syndrome. Conclusion Much remains unknown regarding the pathophysiology of post-viral syndromes, and few studies have provided a comprehensive summary of the condition, agents that cause it, and successful treatment modalities. With the COVID-19 pandemic continuing to affect millions of people worldwide, the need for an understanding of the etiology of post-viral illness and how to help individuals cope with the sequalae is paramount.
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Affiliation(s)
- Caleb Tackey
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Maxwell Slepian
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Nimish Mittal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
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8
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Kounis NG, Gogos C, de Gregorio C, Hung MY, Kounis SN, Tsounis EP, Assimakopoulos SF, Pourmasumi S, Mplani V, Servos G, Dousdampanis P, Plotas P, Michalaki MA, Tsigkas G, Grammatikopoulos G, Velissaris D, Koniar I. "When," "Where," and "How" of SARS-CoV-2 Infection Affects the Human Cardiovascular System: A Narrative Review. Balkan Med J 2024; 41:7-22. [PMID: 38173173 PMCID: PMC10767774 DOI: 10.4274/balkanmedj.galenos.2023.2023-10-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the novel severe acute respiratory coronavirus-2 (SARS-CoV-2). Several explanations for the development of cardiovascular complications during and after acute COVID-19 infection have been hypothesized. The COVID-19 pandemic, caused by SARS-CoV-2, has emerged as one of the deadliest pandemics in modern history. The myocardial injury in COVID-19 patients has been associated with coronary spasm, microthrombi formation, plaque rupture, hypoxic injury, or cytokine storm, which have the same pathophysiology as the three clinical variants of Kounis syndrome. The angiotensin-converting enzyme 2 (ACE2), reninaldosterone system (RAAS), and kinin-kallikrein system are the main proposed mechanisms contributing to cardiovascular complications with the COVID-19 infection. ACE receptors can be found in the heart, blood vessels, endothelium, lungs, intestines, testes, neurons, and other human body parts. SARS-CoV-2 directly invades the endothelial cells with ACE2 receptors and constitutes the main pathway through which the virus enters the endothelial cells. This causes angiotensin II accumulation downregulation of the ACE2 receptors, resulting in prothrombotic effects, such as hemostatic imbalance via activation of the coagulation cascade, impaired fibrinolysis, thrombin generation, vasoconstriction, endothelial and platelet activation, and pro-inflammatory cytokine release. The KKS system typically causes vasodilation and regulates tissue repair, inflammation, cell proliferation, and platelet aggregation, but SARS-CoV-2 infection impairs such counterbalancing effects. This cascade results in cardiac arrhythmias, cardiac arrest, cardiomyopathy, cytokine storm, heart failure, ischemic myocardial injuries, microvascular disease, Kounis syndrome, prolonged COVID, myocardial fibrosis, myocarditis, new-onset hypertension, pericarditis, postural orthostatic tachycardia syndrome, pulmonary hypertension, stroke, Takotsubo syndrome, venous thromboembolism, and thrombocytopenia. In this narrative review, we describe and elucidate when, where, and how COVID-19 affects the human cardiovascular system in various parts of the human body that are vulnerable in every patient category, including children and athletes.
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Affiliation(s)
- Nicholas G. Kounis
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | - Christos Gogos
- Clinic of Cardiology, COVID-19 Unit, Papageorgiou General Hospital, Pavlos Melas, Greece
| | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, University of Messina Medical School, Messina, Italy
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | | | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University Hospital of Patras, Rio, Greece
| | - Stelios F. Assimakopoulos
- Department of Internal Medicine, Division of Infectious Diseases, University of Patras Medical School, Rio, Greece
| | - Soheila Pourmasumi
- Social Determinants of Health Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Virginia Mplani
- Intensive Care Unit, Patras University Hospital, Rio, Greece
| | - George Servos
- Pediatric Cardiology Unit, “P. & A. Kyriakou” Children’s Hospital, Athina, Greece
| | | | - Panagiotis Plotas
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | - Marina A. Michalaki
- Department of Internal Medicine, Division of Endocrinology, University of Patras, School of Health Sciences, Rio, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | | | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras Medical School, Rio, Greece
| | - Ioanna Koniar
- Electrophysiology and Device Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
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Blitshteyn S. Dysautonomia, Hypermobility Spectrum Disorders and Mast Cell Activation Syndrome as Migraine Comorbidities. Curr Neurol Neurosci Rep 2023; 23:769-776. [PMID: 37847487 DOI: 10.1007/s11910-023-01307-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Dysautonomia refers to the dysfunction of the autonomic nervous system and encompasses a wide variety of autonomic symptoms and disorders. The most common autonomic disorders are postural orthostatic tachycardia syndrome (POTS), neurocardiogenic syncope (NCS), and orthostatic hypotension (OH), which may be encountered in clinical practice as part of a triad of dysautonomia, hypermobility spectrum disorders (HSD), and mast cell activation syndrome (MCAS). Migraine is one of the most common comorbidities of POTS, HSD, and MCAS; conversely, these conditions are also prevalent in patients with migraine, especially in those with multiple systemic symptoms, such as chronic dizziness, lightheadedness, orthostatic intolerance, joint pain, and allergic symptoms. Diagnostic criteria, pathophysiologic mechanisms, and therapeutic considerations in patients with migraine and comorbid dysautonomia, HSD, and MCAS are reviewed. RECENT FINDINGS Numerous studies indicate a significant overlap and shared pathophysiology in migraine, dysautonomia, HSD, and MCAS. In clinical setting, dysautonomia, HSD, and MCAS may present a diagnostic and therapeutic challenge in patients with migraine and require a high index of suspicion on the part of the neurologist. Diagnosis and treatment of these complex disorders in patients with migraine is essential to comprehensive patient-centric care, reduced symptom burden, and improved functional impairment secondary to both migraine and comorbidities.
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Affiliation(s)
- Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main Street, Buffalo, NY, 14203, USA.
- Dysautonomia Clinic, 300 International Drive, Suite 100, Williamsville, NY, 14221, USA.
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Semmler A, Mundorf AK, Kuechler AS, Schulze-Bosse K, Heidecke H, Schulze-Forster K, Schott M, Uhrberg M, Weinhold S, Lackner KJ, Pawlitzki M, Meuth SG, Boege F, Ruhrländer J. Chronic Fatigue and Dysautonomia following COVID-19 Vaccination Is Distinguished from Normal Vaccination Response by Altered Blood Markers. Vaccines (Basel) 2023; 11:1642. [PMID: 38005974 PMCID: PMC10674626 DOI: 10.3390/vaccines11111642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
SARS-CoV-2 mRNA vaccination can entail chronic fatigue/dysautonomia tentatively termed post-acute COVID-19 vaccination syndrome (PACVS). We explored receptor autoantibodies and interleukin-6 (IL-6) as somatic correlates of PACVS. Blood markers determined before and six months after first-time SARS-CoV-2 vaccination of healthy controls (N = 89; 71 females; mean/median age: 39/49 years) were compared with corresponding values of PACVS-affected persons (N = 191; 159 females; mean/median age: 40/39 years) exhibiting chronic fatigue/dysautonomia (≥three symptoms for ≥five months after the last SARS-CoV-2 mRNA vaccination) not due to SARS-CoV-2 infection and/or confounding diseases/medications. Normal vaccination response encompassed decreases in 11 receptor antibodies (by 25-50%, p < 0.0001), increases in two receptor antibodies (by 15-25%, p < 0.0001) and normal IL-6. In PACVS, serological vaccination-response appeared significantly (p < 0.0001) altered, allowing discrimination from normal post-vaccination state (sensitivity = 90%, p < 0.0001) by increased Angiotensin II type 1 receptor antibodies (cut-off ≤ 10.7 U/mL, ROC-AUC = 0.824 ± 0.027), decreased alpha-2B adrenergic receptor antibodies (cut-off ≥ 25.2 U/mL, ROC-AUC = 0.828 ± 0.025) and increased IL-6 (cut-off ≤ 2.3 pg/mL, ROC-AUC = 0.850 ± 0.022). PACVS is thus indicated as a somatic syndrome delineated/detectable by diagnostic blood markers.
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Affiliation(s)
- Amelie Semmler
- Central Institute for Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (A.S.); (A.K.M.); (A.S.K.); (K.S.-B.)
| | - Anna Katharina Mundorf
- Central Institute for Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (A.S.); (A.K.M.); (A.S.K.); (K.S.-B.)
| | - Anna Sabrina Kuechler
- Central Institute for Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (A.S.); (A.K.M.); (A.S.K.); (K.S.-B.)
| | - Karin Schulze-Bosse
- Central Institute for Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (A.S.); (A.K.M.); (A.S.K.); (K.S.-B.)
| | - Harald Heidecke
- Cell Trend GmbH, 14943 Luckenwalde, Germany; (H.H.); (K.S.-F.)
| | | | - Matthias Schott
- Division for Specific Endocrinology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany;
| | - Markus Uhrberg
- Institute for Transplantation Diagnostics and Cell Therapeutics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.U.); (S.W.)
| | - Sandra Weinhold
- Institute for Transplantation Diagnostics and Cell Therapeutics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.U.); (S.W.)
| | - Karl J. Lackner
- University Medical Center, Johannes Gutenberg-University Mainz, 55101 Mainz, Germany;
| | - Marc Pawlitzki
- Department of Neurology, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.P.); (S.G.M.)
| | - Sven Guenther Meuth
- Department of Neurology, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.P.); (S.G.M.)
| | - Fritz Boege
- Central Institute for Clinical Chemistry and Laboratory Diagnostics, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (A.S.); (A.K.M.); (A.S.K.); (K.S.-B.)
| | - Jana Ruhrländer
- Selbsthilfegruppe Post-Vac-Syndrom Deutschland e.V., 34121 Kassel, Germany;
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Kawai A, Nagatomo Y, Yukino-Iwashita M, Nakazawa R, Taruoka A, Yumita Y, Takefuji A, Yasuda R, Toya T, Ikegami Y, Masaki N, Ido Y, Adachi T. β 1 Adrenergic Receptor Autoantibodies and IgG Subclasses: Current Status and Unsolved Issues. J Cardiovasc Dev Dis 2023; 10:390. [PMID: 37754819 PMCID: PMC10531529 DOI: 10.3390/jcdd10090390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/28/2023] Open
Abstract
A wide range of anti-myocardial autoantibodies have been reported since the 1970s. Among them, autoantibodies against the β1-adrenergic receptor (β1AR-AAb) have been the most thoroughly investigated, especially in dilated cardiomyopathy (DCM). Β1AR-Aabs have agonist effects inducing desensitization of β1AR, cardiomyocyte apoptosis, and sustained calcium influx which lead to cardiac dysfunction and arrhythmias. Β1AR-Aab has been reported to be detected in approximately 40% of patients with DCM, and the presence of the antibody has been associated with worse clinical outcomes. The removal of anti-myocardial autoantibodies including β1AR-AAb by immunoadsorption is beneficial for the improvement of cardiac function for DCM patients. However, several studies have suggested that its efficacy depended on the removal of AAbs belonging to the IgG3 subclass, not total IgG. IgG subclasses differ in the structure of the Fc region, suggesting that the mechanism of action of β1AR-AAb differs depending on the IgG subclasses. Our previous clinical research demonstrated that the patients with β1AR-AAb better responded to β-blocker therapy, but the following studies found that its response also differed among IgG subclasses. Further studies are needed to elucidate the possible pathogenic role of IgG subclasses of β1AR-AAbs in DCM, and the broad spectrum of cardiovascular diseases including HF with preserved ejection fraction.
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Affiliation(s)
- Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Midori Yukino-Iwashita
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Ryota Nakazawa
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Akira Taruoka
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Yusuke Yumita
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Asako Takefuji
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Risako Yasuda
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Nobuyuki Masaki
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yasuo Ido
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan; (A.K.)
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12
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Kim KT, Lee SU, Kim JB, Choi JY, Kim BJ, Kim JS. Augmented ocular vestibular-evoked myogenic potentials in postural orthostatic tachycardia syndrome. Clin Auton Res 2023; 33:479-489. [PMID: 37115468 DOI: 10.1007/s10286-023-00943-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/08/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE To delineate the association between otolith function and changes in mean orthostatic blood pressure (BP) and heart rate (HR) in patients with postural orthostatic tachycardia syndrome (POTS). METHODS Forty-nine patients with POTS were prospectively recruited. We analyzed the results of ocular vestibular-evoked myogenic potentials (oVEMPs) and cervical vestibular-evoked myogenic potentials (cVEMPs), as well as head-up tilt table tests using a Finometer. The oVEMP and cVEMP responses were obtained using tapping stimuli and 110 dB tone-burst sounds, respectively. We measured maximal changes in 5-s averaged systolic BP (SBP), diastolic BP (DBP), and heart rate (HR) within 15 s and during 10 min after tilting. We compared the results with those of 20 age- and sex-matched healthy participants. RESULTS The n1-p1 amplitude of oVEMPs was larger in patients with POTS than in healthy participants (p = 0.001), whereas the n1 latency (p = 0.280) and interaural difference (p = 0.199) did not differ between the two. The n1-p1 amplitude was a positive predictor for POTS (odds ratio 1.07, 95% confidence interval 1.01-1.13, p = 0.025). Body weight (p = 0.007) and n1-p1 amplitude of oVEMP (p = 0.019) were positive predictors for ΔSBP15s in POTS, whereas aging was a negative predictor (p = 0.005). These findings were not observed in healthy participants. CONCLUSIONS Augmented utricular inputs may be associated with a relative predominance of sympathetic over vagal control of BP and HR, especially for an early response during orthostasis in patients with POTS. Overt sympathoexcitation due to exaggerated utricular input and lack of readaptation may be associated with the pathomechanism of POTS.
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Affiliation(s)
- Keun-Tae Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea.
| | - Jung-Bin Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Jeong-Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
- BK21 FOUR Program in Learning Health Systems, Korea University, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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13
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Zouali M. Pharmacological and Electroceutical Targeting of the Cholinergic Anti-Inflammatory Pathway in Autoimmune Diseases. Pharmaceuticals (Basel) 2023; 16:1089. [PMID: 37631004 PMCID: PMC10459025 DOI: 10.3390/ph16081089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
Continuous dialogue between the immune system and the brain plays a key homeostatic role in various immune responses to environmental cues. Several functions are under the control of the vagus nerve-based inflammatory reflex, a physiological mechanism through which nerve signals regulate immune functions. In the cholinergic anti-inflammatory pathway, the vagus nerve, its pivotal neurotransmitter acetylcholine, together with the corresponding receptors play a key role in modulating the immune response of mammals. Through communications of peripheral nerves with immune cells, it modulates proliferation and differentiation activities of various immune cell subsets. As a result, this pathway represents a potential target for treating autoimmune diseases characterized by overt inflammation and a decrease in vagal tone. Consistently, converging observations made in both animal models and clinical trials revealed that targeting the cholinergic anti-inflammatory pathway using pharmacologic approaches can provide beneficial effects. In parallel, bioelectronic medicine has recently emerged as an alternative approach to managing systemic inflammation. In several studies, nerve electrostimulation was reported to be clinically relevant in reducing chronic inflammation in autoimmune diseases, including rheumatoid arthritis and diabetes. In the future, these new approaches could represent a major therapeutic strategy for autoimmune and inflammatory diseases.
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Affiliation(s)
- Moncef Zouali
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404, Taiwan
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14
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Fan S, Cui Y, Liao Y, Jin H. Predicting Therapeutic Efficacy of Pharmacological Treatments in Children with Postural Orthostatic Tachycardia Syndrome: A Mini-Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1093. [PMID: 37508589 PMCID: PMC10377884 DOI: 10.3390/children10071093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is common in children, with an excessive increment in heart rate when moving from the supine to upright position. It has significant negative impacts on the daily life of pediatric patients. The pathogenesis of POTS includes peripheral vascular dysfunction, central hypovolemia, abnormal autonomic function, a high-adrenergic state, impaired skeletal-muscle pump function, the abnormal release of vasoactive factors, and autoimmune abnormalities. Therefore, the empirical use of pharmacological treatments has limited therapeutic efficacy due to the diversity of its mechanisms. A crucial aspect of managing POTS is the selection of appropriate treatment targeting the specific pathogenesis. This review summarizes the commonly used pharmacological interventions, with a focus on their predictive indicators for treatment response. Factors such as heart rate variability, plasma biomarkers, and cardiac-function parameters are discussed as potential predictors of therapeutic efficacy, enabling the implementation of individualized treatment to improve therapeutic effectiveness. This review consolidates the current knowledge on POTS, encompassing its clinical characteristics, epidemiological patterns, underlying pathogenic mechanisms, and predictive indicators for treatment response. Further research is warranted to enhance the understanding of POTS and facilitate the development of more effective therapeutic approaches for this challenging syndrome.
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Affiliation(s)
- Siying Fan
- Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yaxi Cui
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing 100191, China
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15
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Singh TK, Zidar DA, McCrae K, Highland KB, Englund K, Cameron SJ, Chung MK. A Post-Pandemic Enigma: The Cardiovascular Impact of Post-Acute Sequelae of SARS-CoV-2. Circ Res 2023; 132:1358-1373. [PMID: 37167358 PMCID: PMC10171306 DOI: 10.1161/circresaha.122.322228] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
COVID-19 has become the first modern-day pandemic of historic proportion, affecting >600 million individuals worldwide and causing >6.5 million deaths. While acute infection has had devastating consequences, postacute sequelae of SARS-CoV-2 infection appears to be a pandemic of its own, impacting up to one-third of survivors and often causing symptoms suggestive of cardiovascular phenomena. This review will highlight the suspected pathophysiology of postacute sequelae of SARS-CoV-2, its influence on the cardiovascular system, and potential treatment strategies.
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Affiliation(s)
- Tamanna K Singh
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (TKS, MC, SJC)
- Cleveland Clinic Lerner College of Medicine, OH (T.K.S., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
| | - David A Zidar
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Louise Stokes Cleveland Veterans Affairs Medical Center, Department of Cardiovascular Medicine, Cleveland, OH (D.A.Z.)
| | - Keith McCrae
- Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH (KM)
- Cleveland Clinic Lerner College of Medicine, OH (T.K.S., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
| | - Kristin B Highland
- Pulmonary Medicine, Cleveland Clinic, Cleveland, OH (KBH)
- Cleveland Clinic Lerner College of Medicine, OH (T.K.S., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
| | - Kristin Englund
- Infectious Disease, Cleveland Clinic, Cleveland, OH (KE)
- Cleveland Clinic Lerner College of Medicine, OH (T.K.S., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
| | - Scott J Cameron
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (TKS, MC, SJC)
- Cleveland Clinic Lerner College of Medicine, OH (T.K.S., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
| | - Mina K Chung
- Cleveland Clinic Lerner College of Medicine, OH (T.K.S., K.M., K.B.H., K.E., S.J.C., M.K.C.)
- Case Western Reserve University School of Medicine, Cleveland, OH (T.K.S., D.A.Z., K.M., K.B.H., K.E., S.J.C., M.K.C.)
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16
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Sherif ZA, Gomez CR, Connors TJ, Henrich TJ, Reeves WB. Pathogenic mechanisms of post-acute sequelae of SARS-CoV-2 infection (PASC). eLife 2023; 12:e86002. [PMID: 36947108 PMCID: PMC10032659 DOI: 10.7554/elife.86002] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/10/2023] [Indexed: 03/23/2023] Open
Abstract
COVID-19, with persistent and new onset of symptoms such as fatigue, post-exertional malaise, and cognitive dysfunction that last for months and impact everyday functioning, is referred to as Long COVID under the general category of post-acute sequelae of SARS-CoV-2 infection (PASC). PASC is highly heterogenous and may be associated with multisystem tissue damage/dysfunction including acute encephalitis, cardiopulmonary syndromes, fibrosis, hepatobiliary damages, gastrointestinal dysregulation, myocardial infarction, neuromuscular syndromes, neuropsychiatric disorders, pulmonary damage, renal failure, stroke, and vascular endothelial dysregulation. A better understanding of the pathophysiologic mechanisms underlying PASC is essential to guide prevention and treatment. This review addresses potential mechanisms and hypotheses that connect SARS-CoV-2 infection to long-term health consequences. Comparisons between PASC and other virus-initiated chronic syndromes such as myalgic encephalomyelitis/chronic fatigue syndrome and postural orthostatic tachycardia syndrome will be addressed. Aligning symptoms with other chronic syndromes and identifying potentially regulated common underlining pathways may be necessary for understanding the true nature of PASC. The discussed contributors to PASC symptoms include sequelae from acute SARS-CoV-2 injury to one or more organs, persistent reservoirs of the replicating virus or its remnants in several tissues, re-activation of latent pathogens such as Epstein-Barr and herpes viruses in COVID-19 immune-dysregulated tissue environment, SARS-CoV-2 interactions with host microbiome/virome communities, clotting/coagulation dysregulation, dysfunctional brainstem/vagus nerve signaling, dysautonomia or autonomic dysfunction, ongoing activity of primed immune cells, and autoimmunity due to molecular mimicry between pathogen and host proteins. The individualized nature of PASC symptoms suggests that different therapeutic approaches may be required to best manage specific patients.
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Affiliation(s)
- Zaki A Sherif
- Department of Biochemistry & Molecular Biology, Howard University College of MedicineWashington, District of ColumbiaUnited States
| | - Christian R Gomez
- Division of Lung Diseases, National Institutes of Health (NIH), National Heart, Lung and Blood Institute (NHLBI)BethesdaUnited States
| | - Thomas J Connors
- Department of Pediatrics, Division of Critical Care, Columbia University Vagelos College of Physicians and Surgeons and New York - Presbyterian Morgan Stanley Children's HospitalNew YorkUnited States
| | - Timothy J Henrich
- Division of Experimental Medicine, University of CaliforniaSan FranciscoUnited States
| | - William Brian Reeves
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of TexasSan AntonioUnited States
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17
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El-Rhermoul FZ, Fedorowski A, Eardley P, Taraborrelli P, Panagopoulos D, Sutton R, Lim PB, Dani M. Autoimmunity in Long Covid and POTS. OXFORD OPEN IMMUNOLOGY 2023; 4:iqad002. [PMID: 37255928 PMCID: PMC10224806 DOI: 10.1093/oxfimm/iqad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/23/2023] [Accepted: 03/08/2023] [Indexed: 11/10/2023] Open
Abstract
Orthostatic intolerance and other autonomic dysfunction syndromes are emerging as distinct symptom clusters in Long Covid. Often accompanying these are common, multi-system constitutional features such as fatigue, malaise and skin rashes which can signify generalized immune dysregulation. At the same time, multiple autoantibodies are identified in both Covid-related autonomic disorders and non-Covid autonomic disorders, implying a possible underlying autoimmune pathology. The lack of specificity of these findings precludes direct interpretations of cause and association, but their prevalence with its supporting evidence is compelling.
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Affiliation(s)
- Fatema-Zahra El-Rhermoul
- Department of Allergy and Clinical Immunology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm 171 77, Sweden
| | - Philip Eardley
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | | | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
| | - Phang Boon Lim
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Melanie Dani
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London, London W12 0BZ, UK
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18
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Jammoul M, Naddour J, Madi A, Reslan MA, Hatoum F, Zeineddine J, Abou-Kheir W, Lawand N. Investigating the possible mechanisms of autonomic dysfunction post-COVID-19. Auton Neurosci 2023; 245:103071. [PMID: 36580747 PMCID: PMC9789535 DOI: 10.1016/j.autneu.2022.103071] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 12/10/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
Patients with long COVID suffer from many neurological manifestations that persist for 3 months following infection by SARS-CoV-2. Autonomic dysfunction (AD) or dysautonomia is one complication of long COVID that causes patients to experience fatigue, dizziness, syncope, dyspnea, orthostatic intolerance, nausea, vomiting, and heart palpitations. The pathophysiology behind AD onset post-COVID is largely unknown. As such, this review aims to highlight the potential mechanisms by which AD occurs in patients with long COVID. The first proposed mechanism includes the direct invasion of the hypothalamus or the medulla by SARS-CoV-2. Entry to these autonomic centers may occur through the neuronal or hematogenous routes. However, evidence so far indicates that neurological manifestations such as AD are caused indirectly. Another mechanism is autoimmunity whereby autoantibodies against different receptors and glycoproteins expressed on cellular membranes are produced. Additionally, persistent inflammation and hypoxia can work separately or together to promote sympathetic overactivation in a bidirectional interaction. Renin-angiotensin system imbalance can also drive AD in long COVID through the downregulation of relevant receptors and formation of autoantibodies. Understanding the pathophysiology of AD post-COVID-19 may help provide early diagnosis and better therapy for patients.
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Affiliation(s)
- Maya Jammoul
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Lebanon
| | - Judith Naddour
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Lebanon
| | - Amir Madi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, 90127 Palermo, Italy
| | - Mohammad Amine Reslan
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Firas Hatoum
- Faculty of Medicine, American University of Beirut, Lebanon
| | | | - Wassim Abou-Kheir
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Lebanon
| | - Nada Lawand
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Lebanon; Department of Neurology, Faculty of Medicine, American University of Beirut, Lebanon.
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19
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Deng J, Li H, Guo Y, Zhang G, Fischer H, Stavrakis S, Yu X. Transcutaneous vagus nerve stimulation attenuates autoantibody-mediated cardiovagal dysfunction and inflammation in a rabbit model of postural tachycardia syndrome. J Interv Card Electrophysiol 2023; 66:291-300. [PMID: 35118574 PMCID: PMC9349471 DOI: 10.1007/s10840-022-01144-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/30/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Previous studies demonstrated M2 muscarinic acetylcholine receptor-activating autoantibodies (M2R-AAb) were present in some patients with postural tachycardia syndrome (POTS). This study examines how these autoantibodies might contribute to the pathophysiology of POTS, and whether low-level tragus stimulation (LLTS) can ameliorate autoantibody-mediated autonomic dysregulation in the rabbit. METHODS Five New Zealand white rabbits were immunized with a M2R second extracellular loop peptide to produce cholinomimetic M2R-AAb. Tilt test and infusion studies were performed on conscious rabbits before immunization, 6 weeks after immunization, and 8 weeks after immunization with 2-week daily LLTS treatment. Each rabbit served as its own control. RESULTS Compared to preimmune state, an enhanced heart rate increase and decreased parasympathetic activity upon tilting were observed in immunized rabbits. Furthermore, these rabbits demonstrated an attenuated heart rate-slowing response to infusion of the M2R orthosteric agonist arecaidine propargyl ester (APE), suggesting an inhibitory allosteric effect of M2R-AAb. There was also a significant increase in serum inflammatory cytokines in immunized rabbits. LLTS treatment suppressed the postural tachycardia, improved the sympathovagal balance with increased acetylcholine secretion, reduced the levels of inflammatory cytokines, and reversed the attenuated heart rate response to APE in immunized rabbits. No suppression of M2R-AAb expression by LLTS was found during this short-term study period. Receptor-modulating activity of M2R-AAb produced in immunized rabbits was confirmed with in vitro bioassay. CONCLUSIONS Autoantibody inhibition of cholinergic ligand activity may be involved in the development of cardiovagal dysfunction and inflammation associated with POTS, both of which can be improved by vagal stimulation.
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Affiliation(s)
- Jielin Deng
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Hongliang Li
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Yankai Guo
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Gege Zhang
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Hayley Fischer
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Xichun Yu
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA.
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20
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Low-level tragus stimulation improves autoantibody-induced hyperadrenergic postural tachycardia syndrome in rabbits. Heart Rhythm O2 2023; 4:127-133. [PMID: 36873318 PMCID: PMC9975011 DOI: 10.1016/j.hroo.2022.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Recent studies have demonstrated that antiadrenergic autoantibodies are involved in the pathophysiology of postural orthostatic tachycardia syndrome (POTS). Objective The purpose of this study was to test the hypothesis that transcutaneous low-level tragus stimulation (LLTS) ameliorates autoantibody-induced autonomic dysfunction and inflammation in a rabbit model of autoimmune POTS. Methods Six New Zealand white rabbits were co-immunized with peptides from the α1-adrenergic and β1-adrenergic receptors to produce sympathomimetic antibodies. The tilt test was performed on conscious rabbits before immunization, 6 weeks after immunization, and 10 weeks after immunization with 4-week daily LLTS treatment. Each rabbit served as its own control. Results An enhanced postural heart rate increase in the absence of significant change in blood pressure was observed in immunized rabbits, confirming our previous report. Power spectral analysis of heart rate variability during the tilt test showed a predominance of sympathetic over parasympathetic activity in immunized rabbits as reflected by markedly increased low-frequency power, decreased high-frequency power, and increased low-to-high-frequency ratio. Serum inflammatory cytokines were also significantly increased in immunized rabbits. LLTS suppressed the postural tachycardia, improved the sympathovagal balance with increased acetylcholine secretion, and attenuated the inflammatory cytokine expression. Antibody production and activity were confirmed with in vitro assays, and no antibody suppression by LLTS was found in this short-term study. Conclusion LLTS improves cardiac autonomic imbalance and inflammation in a rabbit model of autoantibody-induced hyperadrenergic POTS, suggesting that LLTS may be used as a novel neuromodulation therapy for POTS.
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21
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Grubb AF, Grubb BP. Postural orthostatic tachycardia syndrome: New concepts in pathophysiology and management. Trends Cardiovasc Med 2023; 33:65-69. [PMID: 34695573 DOI: 10.1016/j.tcm.2021.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/22/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a common and therapeutically challenging condition affecting numerous people worldwide. Recent studies have begun to shed light on the pathophysiology of this disorder. At the same time, both non-pharmacologic and pharmacologic therapies have emerged that offer additional treatment options for those afflicted with this condition. This paper reviews new concepts in both the pathophysiology and management of POTS.
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Affiliation(s)
- Alex F Grubb
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA.
| | - Blair P Grubb
- Division of Cardiology, The University of Toledo Medical Center, Toledo, Ohio, USA
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22
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Tafler L, Chaudry A, Cho H, Garcia A. Management of Post-Viral Postural Orthostatic Tachycardia Syndrome With Craniosacral Therapy. Cureus 2023; 15:e35009. [PMID: 36938206 PMCID: PMC10021347 DOI: 10.7759/cureus.35009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
Postural Orthostatic Tachycardia Syndrome (POTS) is a rare disorder of the autonomic nervous system. The number of people afflicted with this dysautonomia has increased dramatically in recent years due to the long-term effects of coronavirus disease (COVID-19); however, it is largely underdiagnosed. This case report is about a patient with post-viral neuropathic POTS. Neuropathic POTS is believed to be due to the damage of small nerve fibers that regulate the constriction of the blood vessels in the limb and abdomen, which leads to interference with vasoconstriction, and therefore causes tachycardia. Current literature emphasizes a treatment that is based on lifestyle modifications, such as increasing water and salt intake, and symptomatic pharmacological treatment. In this case, the 39-year-old male ptient was treated with osteopathic manipulative treatment (OMT), specifically the compression of the fourth ventricle (CV4), which has been associated with the production of hyperparasympathetic and anti-inflammatory effects and, hence, helps overcome the small-fiber neuropathy caused by the viral illness. We found that the CV4 technique led to the successful remission of the patient's symptoms. Therefore, we propose craniosacral therapy as a successful single management modality in patients with POTS.
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Affiliation(s)
- Leonid Tafler
- Primary Care, Touro College of Osteopathic Medicine, New York City, USA
| | - Aysham Chaudry
- Medical School, Touro College of Osteopathic Medicine, Middletown, USA
| | - Heejin Cho
- Primary Care, Touro College of Osteopathic Medicine, New York City, USA
| | - Angeles Garcia
- Medical School, Touro College of Osteopathic Medicine, New York City, USA
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23
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Sandage MJ, Milstein CF, Nauman E. Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1-17. [PMID: 36383426 DOI: 10.1044/2022_ajslp-22-00187] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.
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Affiliation(s)
- Mary J Sandage
- Department of Speech, Language, and Hearing Sciences, Auburn University, AL
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Narasimhan B, Calambur A, Moras E, Wu L, Aronow W. Postural Orthostatic Tachycardia Syndrome in COVID-19: A Contemporary Review of Mechanisms, Clinical Course and Management. Vasc Health Risk Manag 2023; 19:303-316. [PMID: 37204997 PMCID: PMC10187582 DOI: 10.2147/vhrm.s380270] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
The long-term implications of COVID-19 have garnered increasing interest in recent months, with Long-COVID impacting over 65 million individuals worldwide. Postural orthostatic tachycardia syndrome (POTS) has emerged as an important component of the Long-COVID umbrella, estimated to affect between 2 and 14% of survivors. POTS remains very challenging to diagnose and manage - this review aims to provide a brief overview of POTS as a whole and goes on to summarize the available literature pertaining to POTS in the setting of COVID-19. We provide a review of available clinical reports, outline proposed pathophysiological mechanisms and end with a brief note on management considerations.
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Affiliation(s)
- Bharat Narasimhan
- Department of Cardiology, Debakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | | | - Errol Moras
- Department of Medicine, Icahn School of Medicine; Mount Sinai, New York, NY, USA
| | - Lingling Wu
- Department of Medicine, East Carolina University, Greenvile, NC, USA
| | - Wilbert Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
- Correspondence: Wilbert Aronow, Department of Cardiology, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion, Room 141, Valhalla, NY, 10595, USA, Email
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Self-reported symptom burden in postural orthostatic tachycardia syndrome (POTS): A narrative review of observational and interventional studies. Auton Neurosci 2023; 244:103052. [PMID: 36525900 DOI: 10.1016/j.autneu.2022.103052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/27/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition affecting mostly women of childbearing age, and significantly impacting their health and quality of life. It is currently poorly understood with no approved licensed treatments. The aim of this systematic review was to contextualize the symptom burden of POTS, and review factors associated with this burden that may guide future treatments. The specific questions were (1) How does symptom burden in POTS compare to the burden in other long term conditions (LTCs), (2) Which factors are associated with POTS symptom burden, and (3) Which interventions show promise in reducing symptom burden in POTS. DATABASES AND DATA TREATMENT Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, APA PsycArticles, OpenGrey) were searched from inception to January 2022 for observational studies reporting on the association between any biological, psychological or social factors and symptom burden, and randomized controlled trials reporting on interventions for symptom burden in adults with POTS. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. A narrative synthesis was undertaken. RESULTS/CONCLUSION 5159 entries were screened for eligibility. Twenty-nine studies were included (1372 participants with POTS of a total sample size of 2314, 17 High-, 12 Medium-quality), seventeen were observational and twelve were randomized controlled experimental and intervention trials. Overall methodological quality of the evidence was medium-high but heterogeneity was high and sample sizes modest, allowing moderately robust conclusions. Orthostatic symptom burden was higher in POTS than other LTCs. Serum activity against adrenergic α1 receptors, physical functioning, depression, catastrophizing, prolonged cognitive stress testing and anxiety were significantly associated with symptom burden in medium-high quality studies. Preliminary medium-high quality evidence from predominantly proof-of-concept (n = 11) studies and one 3-month 2 × 2 factorial design trial suggest that compression garments, propranolol, pyridostigmine, desmopressin, and bisoprolol may hold promise in reducing symptom burden. Directions for future research include investigating associated factors over time, the development of complex interventions which address both biological and psychosocial factors associated with symptom burden, and effectiveness trials of these interventions. SIGNIFICANCE POTS symptom burden is high, particularly in relation to orthostatic intolerance when compared to other long-term conditions (LTCs). Despite this burden, there are no effectiveness randomized controlled trials of treatment to reduce symptoms in POTS. This review provides a starting point to understanding researched biological and psychosocial factors associated with this burden. There was however inconsistency in the measurement of symptom burden, lowering the confidence of cross-study inferences. A coherent definition of POTS symptom range, severity and impact along with a validated and reliable POTS-specific instrument is currently lacking. A standardized questionnaire to assess POTS symptom burden as a core outcome measure will help clarify future research and clinical practice.
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Plasma proteomic profiling in postural orthostatic tachycardia syndrome (POTS) reveals new disease pathways. Sci Rep 2022; 12:20051. [PMID: 36414707 PMCID: PMC9681882 DOI: 10.1038/s41598-022-24729-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a cardiovascular autonomic disorder characterized by excessive heart rate increase on standing, leading to debilitating symptoms with limited therapeutic possibilities. Proteomics is a large-scale study of proteins that enables a systematic unbiased view on disease and health, allowing stratification of patients based on their protein background. The aim of the present study was to determine plasma protein biomarkers of POTS and to reveal proteomic pathways differentially regulated in POTS. We performed an age- and sex-matched, case-control study in 130 individuals (case-control ratio 1:1) including POTS and healthy controls. Mean age in POTS was 30 ± 9.8 years (84.6% women) versus controls 31 ± 9.8 years (80.0% women). We analyzed plasma proteins using data-independent acquisition (DIA) mass spectrometry. Pathway analysis of significantly differently expressed proteins was executed using a cutoff log2 fold change set to 1.2 and false discovery rate (p-value) of < 0.05. A total of 393 differential plasma proteins were identified. Label-free quantification of DIA-data identified 30 differentially expressed proteins in POTS compared with healthy controls. Pathway analysis identified the strongest network interactions particularly for proteins involved in thrombogenicity and enhanced platelet activity, but also inflammation, cardiac contractility and hypertrophy, and increased adrenergic activity. Our observations generated by the first use a label-free unbiased quantification reveal the proteomic footprint of POTS in terms of a hypercoagulable state, proinflammatory state, enhanced cardiac contractility and hypertrophy, skeletal muscle expression, and adrenergic activity. These findings support the hypothesis that POTS may be an autoimmune, inflammatory and hyperadrenergic disorder.
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Ormiston CK, Świątkiewicz I, Taub PR. Postural orthostatic tachycardia syndrome as a sequela of COVID-19. Heart Rhythm 2022; 19:1880-1889. [PMID: 35853576 PMCID: PMC9287587 DOI: 10.1016/j.hrthm.2022.07.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/19/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mechanisms of post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess POTS in patients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or β-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.
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Affiliation(s)
- Cameron K Ormiston
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland
| | - Iwona Świątkiewicz
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Department of Cardiology and Internal Medicine, Nicolaus Copernicus University Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Pam R Taub
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California.
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Gravelsina S, Vilmane A, Svirskis S, Rasa-Dzelzkaleja S, Nora-Krukle Z, Vecvagare K, Krumina A, Leineman I, Shoenfeld Y, Murovska M. Biomarkers in the diagnostic algorithm of myalgic encephalomyelitis/chronic fatigue syndrome. Front Immunol 2022; 13:928945. [PMID: 36300129 PMCID: PMC9589447 DOI: 10.3389/fimmu.2022.928945] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/21/2022] [Indexed: 12/02/2022] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex disease that is mainly diagnosed based on its clinical symptoms. Biomarkers that could facilitate the diagnosis of ME/CFS are not yet available; therefore, reliable and clinically useful disease indicators are of high importance. The aim of this work was to analyze the association between ME/CFS clinical course severity, presence of HHV-6A/B infection markers, and plasma levels of autoantibodies against adrenergic and muscarinic acetylcholine receptors. A total of 134 patients with ME/CFS and 33 healthy controls were analyzed for the presence of HHV-6A/B using PCRs, and antibodies against beta2-adrenergic receptors (β2AdR) and muscarinic acetylcholine receptors (M3 AChR and M4 AChR) using ELISAs. HHV-6A/B U3 genomic sequence in whole-blood DNA was detected in 19/31 patients with severe ME/CFS, in 18/73 moderate ME/CFS cases, and in 7/30 mild ME/CFS cases. Severity-related differences were found among those with a virus load of more than 1,000 copies/106 PBMCs. Although no disease severity-related differences in anti-β2AdR levels were observed in ME/CFS patients, the median concentration of these antibodies in plasma samples of ME/CFS patients was 1.4 ng/ml, while in healthy controls, it was 0.81 ng/ml, with a statistically significant increased level in those with ME/CFS (p = 0.0103). A significant difference of antibodies against M4 AChR median concentration was found between ME/CFS patients (8.15 ng/ml) and healthy controls (6.45 ng/ml) (p = 0.0250). The levels of anti-M4 plotted against disease severity did not show any difference; however, increased viral load correlates with the increase in anti-M4 level. ME/CFS patients with high HHV-6 load have a more severe course of the disease, thus confirming that the severity of the disease depends on the viral load—the course of the disease is more severe with a higher viral load. An increase in anti-M4 AchR and anti-β2AdR levels is detected in all ME/CFS patient groups in comparison to the control group not depending on ME/CFS clinical course severity. However, the increase in HHV-6 load correlates with the increase in anti-M4 level, and the increase in anti-M4 level, in turn, is associated with the increase in anti-β2AdR level. Elevated levels of antibodies against β2AdR and M4 receptors in ME/CFS patients support their usage as clinical biomarkers in the diagnostic algorithm of ME/CFS.
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Affiliation(s)
- Sabine Gravelsina
- Institute of Microbiology and Virology, Rīga Stradiņš University, Riga, Latvia
- *Correspondence: Sabine Gravelsina,
| | - Anda Vilmane
- Institute of Microbiology and Virology, Rīga Stradiņš University, Riga, Latvia
| | - Simons Svirskis
- Institute of Microbiology and Virology, Rīga Stradiņš University, Riga, Latvia
| | | | - Zaiga Nora-Krukle
- Institute of Microbiology and Virology, Rīga Stradiņš University, Riga, Latvia
| | - Katrine Vecvagare
- Institute of Microbiology and Virology, Rīga Stradiņš University, Riga, Latvia
| | - Angelika Krumina
- Department of Infectology, Rīga Stradiņš University, Riga, Latvia
| | - Iana Leineman
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Modra Murovska
- Institute of Microbiology and Virology, Rīga Stradiņš University, Riga, Latvia
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Hall J, Bourne KM, Vernino S, Hamrefors V, Kharraziha I, Nilsson J, Sheldon RS, Fedorowski A, Raj SR. Detection of G Protein-Coupled Receptor Autoantibodies in Postural Orthostatic Tachycardia Syndrome Using Standard Methodology. Circulation 2022; 146:613-622. [PMID: 35766055 PMCID: PMC9390234 DOI: 10.1161/circulationaha.122.059971] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is a disorder of orthostatic intolerance that primarily affects women of childbearing age. The underlying pathophysiology of POTS is not fully understood, but it has been suggested that autoimmunity may play a role. The aim of this study was to compare concentrations of autoantibodies to cardiovascular G protein-coupled receptors between patients with POTS and healthy controls. METHODS Sera were collected from 116 patients with POTS (91% female; medium age, 29 years) and 81 healthy controls (84% female; medium age, 27 years) from Calgary, Canada, and Malmö, Sweden. Samples were evaluated for autoantibodies to 11 receptors (adrenergic, muscarinic, angiotensin II, and endothelin) using a commercially available enzyme-linked immunosorbent assay. RESULTS Autoantibody concentrations against all of the receptors tested were not significantly different between controls and patients with POTS. The majority of patients with POTS (98.3%) and all controls (100%) had α1 adrenergic receptor autoantibody concentrations above the seropositive threshold provided by the manufacturer (7 units/mL). The proportion of patients with POTS versus healthy controls who fell above the diagnostic thresholds was not different for any tested autoantibodies. Receiver operating characteristic curves showed a poor ability to discriminate between patients with POTS and controls. CONCLUSIONS Patients with POTS and healthy controls do not differ in their enzyme-linked immunosorbent assay-derived autoantibody concentrations to cardiovascular G protein-coupled receptors. These findings suggest that these tests are not useful for establishing the role of autoimmunity in POTS.
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Affiliation(s)
- Juliette Hall
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.)
| | - Kate M. Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.)
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX (S.V.)
| | - Viktor Hamrefors
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden (V.H.)
| | - Isabella Kharraziha
- Department of Clinical Sciences, Lund University, Malmö, Sweden (V.H., I.K., J.N., A.F.)
| | - Jan Nilsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden (V.H., I.K., J.N., A.F.)
| | - Robert S. Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.)
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden (V.H., I.K., J.N., A.F.).,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (A.F.)
| | - Satish R. Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.).,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (S.R.R.)
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Rodriguez B, Hochstrasser A, Eugster PJ, Grouzmann E, Müri RM, Z’Graggen WJ. Brain fog in neuropathic postural tachycardia syndrome may be associated with autonomic hyperarousal and improves after water drinking. Front Neurosci 2022; 16:968725. [PMID: 35992935 PMCID: PMC9388780 DOI: 10.3389/fnins.2022.968725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background Brain fog is a common and highly disturbing symptom for patients with neuropathic postural tachycardia syndrome (POTS). Cognitive deficits have been measured exclusively in the upright body position and mainly comprised impairments of higher cognitive functions. The cause of brain fog is still unclear today. This study aimed to investigate whether increased autonomic activation might be an underlying mechanism for the occurrence of brain fog in neuropathic POTS. We therefore investigated cognitive function in patients with neuropathic POTS and a healthy control group depending on body position and in relation to catecholamine release as a sensitive indicator of acute stress. The second aim was to test the effect of water intake on cardiovascular regulation, orthostatic symptoms, cognitive function and catecholamine release. Methods Thirteen patients with neuropathic POTS and 15 healthy control subjects were included. All participants completed a total of four rounds of cognitive testing: two before and two after the intake of 500 ml still water, each first in the supine position and then during head-up tilt. At the end of each cognitive test, a blood sample was collected for determination of plasma catecholamines. After each head-up tilt phase participants were asked to rate their current symptoms on a visual analogue scale. Results Working memory performance in the upright body position was impaired in patients, which was associated with self-reported symptom severity. Patients had elevated plasma norepinephrine independent of body position and water intake that increased excessively in the upright body position. The excessive increase of plasma norepinephrine was related to heart rate and symptom severity. Water intake in patients decreased norepinephrine concentrations and heart rate, and improved symptoms as well as cognitive performance. Conclusion Brain fog and symptom severity in neuropathic POTS are paralleled by an excessive norepinephrine secretion. Bolus water drinking down-regulates norepinephrine secretion and improves general symptom severity including brain fog.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annie Hochstrasser
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philippe J. Eugster
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Grouzmann
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - René M. Müri
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Werner J. Z’Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- *Correspondence: Werner J. Z’Graggen,
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Lehmann HC. Neuromuskuläre Manifestationen beim Long-COVID-Syndrom. DER NERVENARZT 2022; 93:761-768. [PMID: 35852546 PMCID: PMC9294793 DOI: 10.1007/s00115-022-01321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 12/15/2022]
Abstract
Unter dem Long-COVID(„coronavirus disease“)-Syndrom werden Beschwerden zusammengefasst, die nach einer akuten SARS-CoV-2(„severe acute respiratory syndrome coronavirus type 2“)-Infektion auftreten, über einen Zeitraum von mehreren Wochen anhalten und nicht durch eine andere Diagnose erklärt werden können. Long-COVID wird als Multiorganmanifestation aufgefasst. In diesem Übersichtsartikel wird die Datenlage hinsichtlich neuromuskulärer Manifestationen des Long-COVID-Syndroms summiert und anhand von Kriterien wie Effektstärke, Plausibilität, Kohärenz und experimentelle Evidenz bewertet. Bisher sind vor allem Myalgien und eine autonome Dysfunktion (u. a. das posturale Tachykardiesyndrom) als neuromuskuläre Symptome von Long-COVID beschrieben worden. Die bisherige Evidenz ist allerdings gering: Neben einer sehr heterogenen Methodik und unterschiedlichen Definitionen in den klinischen Long-COVID-Studien fehlen schlüssige experimentelle Daten, die die beschriebenen Symptome als spezifische Langzeitfolge von COVID-19 belegen.
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Long COVID: Association of Functional Autoantibodies against G-Protein-Coupled Receptors with an Impaired Retinal Microcirculation. Int J Mol Sci 2022; 23:ijms23137209. [PMID: 35806214 PMCID: PMC9266742 DOI: 10.3390/ijms23137209] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 02/05/2023] Open
Abstract
Long COVID (LC) describes the clinical phenotype of symptoms after infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Diagnostic and therapeutic options are limited, as the pathomechanism of LC is elusive. As the number of acute SARS-CoV-2 infections was and is large, LC will be a challenge for the healthcare system. Previous studies revealed an impaired blood flow, the formation of microclots, and autoimmune mechanisms as potential factors in this complex interplay. Since functionally active autoantibodies against G-protein-coupled receptors (GPCR-AAbs) were observed in patients after SARS-CoV-2 infection, this study aimed to correlate the appearance of GPCR-AAbs with capillary microcirculation. The seropositivity of GPCR-AAbs was measured by an established cardiomyocyte bioassay in 42 patients with LC and 6 controls. Retinal microcirculation was measured by OCT–angiography and quantified as macula and peripapillary vessel density (VD) by the Erlangen-Angio Tool. A statistical analysis yielded impaired VD in patients with LC compared to the controls, which was accentuated in female persons. A significant decrease in macula and peripapillary VD for AAbs targeting adrenergic β2-receptor, MAS-receptor angiotensin-II-type-1 receptor, and adrenergic α1-receptor were observed. The present study might suggest that a seropositivity of GPCR-AAbs can be linked to an impaired retinal capillary microcirculation, potentially mirroring the systemic microcirculation with consecutive clinical symptoms.
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The Pathophysiology of Long COVID throughout the Renin-Angiotensin System. Molecules 2022; 27:molecules27092903. [PMID: 35566253 PMCID: PMC9101946 DOI: 10.3390/molecules27092903] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 01/08/2023] Open
Abstract
COVID-19 has expanded across the world since its discovery in Wuhan (China) and has had a significant impact on people’s lives and health. Long COVID is a term coined by the World Health Organization (WHO) to describe a variety of persistent symptoms after acute SARS-CoV-2 infection. Long COVID has been demonstrated to affect various SARS-CoV-2-infected persons, independently of the acute disease severity. The symptoms of long COVID, like acute COVID-19, consist in the set of damage to various organs and systems such as the respiratory, cardiovascular, neurological, endocrine, urinary, and immune systems. Fatigue, dyspnea, cardiac abnormalities, cognitive and attention impairments, sleep disturbances, post-traumatic stress disorder, muscle pain, concentration problems, and headache were all reported as symptoms of long COVID. At the molecular level, the renin-angiotensin system (RAS) is heavily involved in the pathogenesis of this illness, much as it is in the acute phase of the viral infection. In this review, we summarize the impact of long COVID on several organs and tissues, with a special focus on the significance of the RAS in the disease pathogenesis. Long COVID risk factors and potential therapy approaches are also explored.
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Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS. CURRENT PEDIATRICS REPORTS 2022; 10:31-44. [PMID: 35287333 PMCID: PMC8906524 DOI: 10.1007/s40124-022-00261-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 12/13/2022]
Abstract
Purpose of Review To discuss emerging understandings of adolescent long COVID or post-COVID-19 conditions, including proposed clinical definitions, common symptoms, epidemiology, overlaps with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and orthostatic intolerance, and preliminary guidance on management. Recent Findings The recent World Health Organization clinical case definition of post-COVID-19 condition requires a history of probable or confirmed SARS-CoV-2 infection, with symptoms starting within 3 months of the onset of COVID-19. Symptoms must last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms of the post-COVID-19 condition include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction. These symptoms generally have an impact on everyday functioning. The incidence of prolonged symptoms following SARS-CoV-2 infection has proven challenging to define, but it is now clear that those with relatively mild initial infections, without severe initial respiratory disease or end-organ injury, can still develop chronic impairments, with symptoms that overlap with conditions like ME/CFS (profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance). Summary We do not yet have a clear understanding of the mechanisms by which individuals develop post-COVID-19 conditions. There may be several distinct types of long COVID that require different treatments. At this point, there is no single pharmacologic agent to effectively treat all symptoms. Because some presentations of post-COVID-19 conditions mimic disorders such as ME/CFS, treatment guidelines for this and related conditions can be helpful for managing post-COVID-19 symptoms. Supplementary Information The online version contains supplementary material available at 10.1007/s40124-022-00261-4.
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Platelet Storage Pool Deficiency and Elevated Inflammatory Biomarkers Are Prevalent in Postural Orthostatic Tachycardia Syndrome. Cells 2022; 11:cells11050774. [PMID: 35269395 PMCID: PMC8909348 DOI: 10.3390/cells11050774] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/01/2023] Open
Abstract
A significant number of postural orthostatic tachycardia syndrome (POTS) patients have platelet delta granule storage pool deficiency (δ-SPD). The etiology of POTS is unknown but a number of laboratories, including ours, have reported elevations of G-protein-coupled adrenergic receptor and muscarinic acetylcholine receptor autoantibodies in POTS patients, detected by a variety of techniques, suggesting that the disorder is an autoimmune condition. Thus, it could also be considered an inflammatory disease. In a pilot study, we investigated a limited number of platelet-related cytokines and chemokines and discovered many that were elevated. This case−control study validates our pilot study results that POTS patients have an activated innate immune system. Plasma of 35 POTS patients and 35 patients with unexplained bleeding symptoms and categorized as “non-POTS” subjects was analyzed by multiplex flow cytometry to quantify 16 different innate immune system cytokines and chemokines. Electron microscopy was used to quantify platelet dense granules. Ten of 16 biomarkers of inflammation were elevated in plasma from POTS patients compared to non-POTS subjects, with most of the differences extremely significant, with p values < 0.0001. Of particular interest were elevations of IL-1β and IL-18 and decreased or normal levels of type 1 interferons in POTS patients, suggesting that the etiology of POTS might be autoinflammatory. All POTS patients had δ-SPD. With a growing body of evidence that POTS is an autoimmune disease and having elevations of the innate immune system, our results suggest a potential T-cell-mediated autoimmunity in POTS characteristic of a mixed-pattern inflammatory disease similar to rheumatoid arthritis.
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Jost K, Rodriguez B, Söll N, Hoepner R, Z'Graggen WJ. Tolerability of COVID-19 mRNA vaccines in patients with postural tachycardia syndrome: a cross-sectional study. F1000Res 2022; 11:215. [PMID: 37822957 PMCID: PMC10562791 DOI: 10.12688/f1000research.109373.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 10/13/2023] Open
Abstract
Background: Postural tachycardia syndrome (POTS) is a form of autonomic dysregulation. There is increasing evidence that the etiology may be immune-mediated in a subgroup of patients. Patients with POTS often experience an exacerbation of their symptoms associated with (viral) infections and often fear the same symptom aggravation after vaccination. In this report we describe the tolerability of messenger ribonucleic acid (mRNA) vaccines against coronavirus disease 19 (COVID-19) and the consequences of a COVID-19 infection on POTS symptoms in our cohort of patients with neuropathic POTS. Methods: We conducted a standardized, checklist-based interview with 23 patients and recorded the acute side effects of mRNA vaccination, acute symptoms of COVID-19 infection as well as the effects of vaccination and COVID-19 infection on POTS symptoms. Results: Of all included patients, 20 patients received two mRNA vaccines without having had a previous COVID-19 infection, and five patients in total had suffered a COVID-19 infection. Of these, three had COVID-19 without and two after being vaccinated. No increased frequency of side effects after both doses of mRNA vaccines was observed. Six patients reported a mild and short-term aggravation of their POTS symptoms beyond the duration of acute vaccine side effects. All five patients who suffered a COVID-19 infection subsequently reported a pronounced and persistent exacerbation of POTS symptoms. Conclusions: Our observations suggest that mRNA vaccines are not associated with a higher frequency of acute side effects in patients with POTS. Symptom exacerbation as a consequence of mRNA vaccination seems to be less frequent and of shorter duration compared to patients who suffered a COVID-19 infection.
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Affiliation(s)
- Karin Jost
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Belén Rodriguez
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Werner J. Z'Graggen
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
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Dotan A, David P, Arnheim D, Shoenfeld Y. The autonomic aspects of the post-COVID19 syndrome. Autoimmun Rev 2022; 21:103071. [PMID: 35182777 PMCID: PMC8848724 DOI: 10.1016/j.autrev.2022.103071] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 01/04/2023]
Abstract
The SARS-CoV-2 outbreak, responsible for the widespread COVID-19, led to one of the most rogue pandemics in modern time, yet the major effects of the pandemic may still be ahead of us. SARS-CoV-2 had been found to possess autoimmune properties. Close to 20 distinct autoantibodies which target GPCR of the nervous system and renin-angiotensin system-related molecules were found significantly associated with the clinical severity of COVID-19. The new on-set of more than 10 various autoimmune disorders were documented as well. Additionally, clinical presentations of persisted symptoms were triggered in numerous recently recovered COVID-19 patients, which led to the formulation of the novel term “post-COVID19 syndrome”. Manifestations related to post-COVID-19 syndrome exist among approximately 50–80% of symptomatic COVID-19 patients who recovered, and among patients reported more than 50 different long-term effects of the SARS-CoV-2 infection. Many of the common symptoms of the post-COVID19 syndrome are not explained by the virus-related injury alone. Similarly to chronic fatigue syndrome and fibromyalgia, autoimmune-mediated autonomic nervous system dysfunction may play a significant part in the pathogenesis of such symptoms, including chronic fatigue, cognitive impairment, mood related disorders, and numerous more. Importantly, therapeutic options such as immunomodulatory and immunosuppressive therapy may favor some post-COVID19 patients, while plasmapheresis and IVIG could be considered in severe cases. Nevertheless, as physical exercise has been found to stabilize the autonomic nervous system, exercise therapy might be a safer and more effective remedy for the post-COVID19 syndrome.
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Affiliation(s)
- Arad Dotan
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Paula David
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel
| | - Dana Arnheim
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Laboratory of the Mosaics of Autoimmunity, Saint Petersburg University, 199034, Russia
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Association of autoantibodies to muscarinic acetylcholine receptors with gastrointestinal symptoms and disease severity in patients with postural orthostatic tachycardia syndrome. Immunol Res 2022; 70:197-207. [PMID: 34993884 DOI: 10.1007/s12026-021-09256-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/01/2021] [Indexed: 11/05/2022]
Abstract
Previous studies have reported a relationship between postural orthostatic tachycardia syndrome (POTS) and positivity for serum autoantibodies against G-protein-coupled receptors (GPCRs). However, the role of these autoantibodies in POTS is unclear. The present retrospective study analyzed the autoimmune etiology of POTS in 24 patients using a head-up tilt test to assess for any correlation between the clinical features of POTS and serum levels of autoantibodies against diverse GPCRs. In total, ten assessment items, including autonomic function tests, were analyzed. Of these, persistent, gastrointestinal symptoms and disease severity showed a significant association with the serum level of anti-muscarinic acetylcholine receptor (mAChRs) antibodies (gastrointestinal symptoms, M1, M2, M5; disease severity, M1, M3, M4, M5) [P <0.05]), while no significant association was found between the clinical features and autoantibodies against adrenergic receptors (α1, α2, β1, β2), angiotensin receptor 1, or endothelin receptor A. The patients were further divided into two groups based on the presence or absence of persistent gastrointestinal symptoms and then were characterized by the ten assessment items and neuropsychological tests, including the Wechsler Adult Intelligence Scale score and Self-Rating Depression Scale score. The results demonstrated a clear difference between the two groups in terms of disease severity, age at onset (older or younger than 20 years), and processing speed index (P <0.05), which were highly consistent with the association between these clinical features and the levels of serum anti-mAChR antibodies, particularly the anti-M5 receptor antibody. These findings suggested that anti-mAChR antibodies may play an important role in a subgroup of POTS patients with persistent gastrointestinal symptoms.
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Postural tachycardia syndrome (POTS) and antiphospholipid syndrome (APS): What do we know so far? Rev Neurol (Paris) 2021; 178:306-314. [PMID: 34895744 DOI: 10.1016/j.neurol.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
As part of the non-criteria clinical manifestations, postural orthostatic tachycardia syndrome (POTS), a multisystem autonomic dysfunction, can co-exist with antiphospholipid syndrome (APS). Several pieces of evidence hint on the autoimmune basis of POTS, and its possible association with several autoimmune diseases, including APS. Indeed, the evidence exists in the etiologies, symptomatology, and treatment options. Although infections, viral ones in particular, stress, and pregnancy are etiologies to both POTS and APS, the exact pathophysiological connection is still to be studied taking into consideration the activity of cytokines in both diseases. Nevertheless, certain immunomodulatory treatments used for the catastrophic or obstetrical forms of APS, such as intravenous immunoglobulins (IVIG) and steroids, have been also used for the treatment of POTS resistant to classical treatments. Therefore, our review aims to highlight the association between POTS and APS, shedding light on the common etiologies explaining the pathophysiology of the two disorders, the diagnostic approach to POTS as a possible clinical criterion of APS, and the treatment of APS in the context of treating POTS.
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Dysautonomia Following Tetanus, Diphtheria, and Pertussis Vaccine (Tdap): The First Case of Extreme Cachexia Caused by Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA Syndrome) in a Human. Medicina (B Aires) 2021; 57:medicina57121333. [PMID: 34946278 PMCID: PMC8704925 DOI: 10.3390/medicina57121333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 12/05/2022] Open
Abstract
Autoimmune/inflammatory Syndrome Induced by Adjuvants (ASIA; Shoenfeld’s syndrome) comprehends a group of autoimmune conditions that flourish in genetically predisposed individuals, following an external stimulus by the so-called adjuvants. Many adjuvants were described, such as vaccines, aluminum and other metals, silicone, tattoos, among others. Those conditions entail defined diseases, such as sarcoidosis and Sjogren’s syndrome, and generalized complex symptoms, for example, fatigue, sleep disturbance, orthostatic intolerance, and other dysautonomic manifestations. Those complaints were previously associated with autoantibodies against nervous system autonomic receptors, especially antibeta 1 adrenergic receptor antibodies, suggesting the autoimmune component of the condition. Here we report on a case of an 18-year-old woman who presented with extreme cachexia due to severe dysautonomia caused by the ASIA syndrome induced by the tetanus, diphtheria, and pertussis vaccine (Tdap).
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Mathias CJ, Owens A, Iodice V, Hakim A. Dysautonomia in the Ehlers-Danlos syndromes and hypermobility spectrum disorders-With a focus on the postural tachycardia syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:510-519. [PMID: 34766441 DOI: 10.1002/ajmg.c.31951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/22/2021] [Indexed: 12/14/2022]
Abstract
Dysautonomia (autonomic dysfunction) occurs in the Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD). Symptoms include palpitations, dizziness, presyncope, and syncope, especially when standing upright. Symptoms of orthostatic intolerance are usually relieved by sitting or lying and may be exacerbated by stimuli in daily life that cause vasodilatation, such as food ingestion, exertion, and heat. Neurocardiovascular dysautonomia may result in postural tachycardia syndrome (PoTS), a major cause of orthostatic intolerance. It is defined by a rise in heart rate of >30 beats per minute (bpm) in adults and >40 bpm in teenagers while upright, without a fall in blood pressure (BP; orthostatic hypotension). In some, it can be compounded by the presence of low BP. For many, there is delay in clinicians recognizing the nature of the symptoms, and recognizing EDS or HSD, leading to delays in treatment. The onset of PoTS may be linked to an event such as infection, trauma, surgery, or stress. Gastrointestinal and urinary bladder involvement may occur, along with thermoregulatory dysfunction. In some, the mast cell activation syndrome may be contributary, especially if it causes vasodilatation. This paper reviews neurocardiovascular dysautonomia with an emphasis on PoTS, its characteristics, associations, pathophysiology, investigation, and treatment.
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Affiliation(s)
- Christopher J Mathias
- UCL Queen Square Institute of Neurology, University College London, London, UK.,The Lindo Wing, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK.,Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | - Andrew Owens
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Valeria Iodice
- UCL Queen Square Institute of Neurology, University College London, London, UK.,Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, UK
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Maintenance therapy with subcutaneous immunoglobulin in a patient with immune-mediated neuropathic postural tachycardia syndrome. J Transl Autoimmun 2021; 4:100112. [PMID: 34471867 PMCID: PMC8387908 DOI: 10.1016/j.jtauto.2021.100112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/14/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Aims We describe the disease course of a 35-year-old female with an autoimmune mediated neuropathic postural tachycardia syndrome (PoTS), who responded to immunoglobulin therapy and stabilized on maintenance therapy with subcutaneous immunoglobulin (SCIg). Methods We provide longitudinal data of clinical scores, tilt-table results and antibody titers. Results Initial treatment with intravenous immunoglobulin caused infusion-related side-effects whereas SCIg was well tolerated and improved clinical symptoms and quality of life. Clinical improvement correlated with the reduction of serum antibody titers 22 months after first infusion. Conclusions These findings suggest that autoimmune-mediated neuropathic PoTS can be treated sufficiently with IVIg whereas SCIg minimizes side-effects.
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Freitag H, Szklarski M, Lorenz S, Sotzny F, Bauer S, Philippe A, Kedor C, Grabowski P, Lange T, Riemekasten G, Heidecke H, Scheibenbogen C. Autoantibodies to Vasoregulative G-Protein-Coupled Receptors Correlate with Symptom Severity, Autonomic Dysfunction and Disability in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. J Clin Med 2021; 10:3675. [PMID: 34441971 PMCID: PMC8397061 DOI: 10.3390/jcm10163675] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is an acquired complex disease with patients suffering from the cardinal symptoms of fatigue, post-exertional malaise (PEM), cognitive impairment, pain and autonomous dysfunction. ME/CFS is triggered by an infection in the majority of patients. Initial evidence for a potential role of natural regulatory autoantibodies (AAB) to beta-adrenergic (AdR) and muscarinic acetylcholine receptors (M-AChR) in ME/CFS patients comes from a few studies. METHODS Here, we analyzed the correlations of symptom severity with levels of AAB to vasoregulative AdR, AChR and Endothelin-1 type A and B (ETA/B) and Angiotensin II type 1 (AT1) receptor in a Berlin cohort of ME/CFS patients (n = 116) by ELISA. The severity of disease, symptoms and autonomic dysfunction were assessed by questionnaires. RESULTS We found levels of most AABs significantly correlated with key symptoms of fatigue and muscle pain in patients with infection-triggered onset. The severity of cognitive impairment correlated with AT1-R- and ETA-R-AAB and severity of gastrointestinal symptoms with alpha1/2-AdR-AAB. In contrast, the patients with non-infection-triggered ME/CFS showed fewer and other correlations. CONCLUSION Correlations of specific AAB against G-protein-coupled receptors (GPCR) with symptoms provide evidence for a role of these AAB or respective receptor pathways in disease pathomechanism.
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Affiliation(s)
- Helma Freitag
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Marvin Szklarski
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Sebastian Lorenz
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Franziska Sotzny
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Sandra Bauer
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Aurélie Philippe
- Department of Nephrology and Critical Care Medicine, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Claudia Kedor
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Patricia Grabowski
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Tanja Lange
- Department of Rheumatology and Clinical Immunology, University of Lübeck, 23538 Lübeck, Germany; (T.L.); (G.R.)
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, 23538 Lübeck, Germany; (T.L.); (G.R.)
| | | | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
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Implications of Antimuscarinic Autoantibodies in Postural Tachycardia Syndrome. J Cardiovasc Transl Res 2021; 15:438-440. [PMID: 34409582 DOI: 10.1007/s12265-021-10167-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Functional autoantibodies directed to the M2 muscarinic acetylcholine receptor (M2R) could affect the heart rate directly by altering cardiac M2R activity and/or indirectly by changing vagal-mediated cardiac M2R activity. We measured M2R autoantibody activity in sera from 10 subjects with postural tachycardia syndrome (POTS) and 5 healthy control subjects using a cell-based bioassay. Half of the POTS subjects demonstrated presence of elevated M2R autoantibody activity, while no significant M2R autoantibody activity was found in the healthy subjects. Serum-derived immunoglobulin G (IgG) from antibody-positive POTS patients induced a dose-dependent activation of M2R, which was blocked by the muscarinic antagonist atropine. Moreover, antibody-positive POTS IgG decreased the responsiveness to oxotremorine, an orthosteric muscarinic agonist, indicating an indirect inhibitory effect. These data suggest that M2R autoantibodies may contribute to the pathophysiology of POTS by increasing the normal vagal withdrawal during upright posture through its negative allosteric modulation of M2R activity. M2 muscarinic receptor-activating autoantibodies are present in a subgroup of patients with POTS and act as a negative allosteric modulator of the orthosteric ligand response.
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Larsen NW, Stiles LE, Miglis MG. Preparing for the long-haul: Autonomic complications of COVID-19. Auton Neurosci 2021; 235:102841. [PMID: 34265539 PMCID: PMC8254396 DOI: 10.1016/j.autneu.2021.102841] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/13/2021] [Accepted: 06/28/2021] [Indexed: 12/25/2022]
Abstract
As global numbers of COVID-19 grow, chronic neurological symptoms, including those of autonomic dysfunction, are being reported with increasing frequency. Mounting evidence suggests that many patients experience chronic and sometimes debilitating symptoms long after their acute infectious period, leading to the new diagnostic category of post-acute COVID syndrome. Many symptoms of post-acute COVID syndrome appear autonomic in nature, suggesting that autonomic impairment may play a central role in the underlying pathophysiology. In this review, we discuss the autonomic symptoms and manifestations of post-acute COVID syndrome, potential mechanisms involved, and future directions for a better understanding of this novel condition.
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Affiliation(s)
- Nicholas W Larsen
- Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA, USA
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA, USA.
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Raj SR, Bourne KM, Stiles LE, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Diedrich A, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Darbari A, Vernino S. Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting - Part 2. Auton Neurosci 2021; 235:102836. [PMID: 34246578 PMCID: PMC8455430 DOI: 10.1016/j.autneu.2021.102836] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
The National Institutes of Health hosted a workshop in 2019 to build consensus around the current state of understanding of the pathophysiology of postural orthostatic tachycardia syndrome (POTS) and to identify knowledge gaps that must be addressed to enhance clinical care of POTS patients through research. This second (of two) articles summarizes current knowledge gaps, and outlines the clinical and research priorities for POTS. POTS is a complex, multi-system, chronic disorder of the autonomic nervous system characterized by orthostatic intolerance and orthostatic tachycardia without hypotension. Patients often experience a host of other related disabling symptoms. The functional and economic impacts of this disorder are significant. The pathophysiology remains incompletely understood. Beyond the significant gaps in understanding the disorder itself, there is a paucity of evidence to guide treatment which can contribute to suboptimal care for this patient population. The vast majority of physicians have minimal to no familiarity or training in the assessment and management of POTS. Funding for POTS research remains very low relative to the size of the patient population and impact of the syndrome. In addition to efforts to improve awareness and physician education, an investment in research infrastructure including the development of standardized disease-specific evaluation tools and outcome measures is needed to facilitate effective collaborative research. A national POTS research consortium could facilitate well-controlled multidisciplinary clinical research studies and therapeutic trials. These priorities will require a substantial increase in the number of research investigators and the amount of research funding in this area.
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Affiliation(s)
- Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY USA
| | - Amy C Arnold
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Anil Darbari
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Diedrich A, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Darbari A, Raj SR. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci 2021; 235:102828. [PMID: 34144933 DOI: 10.1016/j.autneu.2021.102828] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/10/2021] [Accepted: 05/30/2021] [Indexed: 12/13/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a chronic and often disabling disorder characterized by orthostatic intolerance with excessive heart rate increase without hypotension during upright posture. Patients often experience a constellation of other typical symptoms including fatigue, exercise intolerance and gastrointestinal distress. A typical patient with POTS is a female of child-bearing age, who often first displays symptoms in adolescence. The onset of POTS may be precipitated by immunological stressors such as a viral infection. A variety of pathophysiologies are involved in the abnormal postural tachycardia response; however, the pathophysiology of the syndrome is incompletely understood and undoubtedly multifaceted. Clinicians and researchers focused on POTS convened at the National Institutes of Health in July 2019 to discuss the current state of understanding of the pathophysiology of POTS and to identify priorities for POTS research. This article, the first of two articles summarizing the information discussed at this meeting, summarizes the current understanding of this disorder and best practices for clinical care. The evaluation of a patient with suspected POTS should seek to establish the diagnosis, identify co-morbid conditions, and exclude conditions that could cause or mimic the syndrome. Once diagnosed, management typically begins with patient education and non-pharmacologic treatment options. Various medications are often used to address specific symptoms, but there are currently no FDA-approved medications for the treatment of POTS, and evidence for many of the medications used to treat POTS is not robust.
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Affiliation(s)
- Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY, USA
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington Univeristy School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Anil Darbari
- Pediatric Gastroenterology, Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Harnish PR, Shastri P, Grubb BP. Sick Sinus Syndrome Can Be Associated with Postural Tachycardia Syndrome and Inappropriate Sinus Tachycardia Syndrome. J Innov Card Rhythm Manag 2021; 12:4526-4531. [PMID: 34035985 PMCID: PMC8139308 DOI: 10.19102/icrm.2021.120503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/09/2020] [Indexed: 11/21/2022] Open
Abstract
As a known phenomenon, crossover between sinus node dysfunction and common atrial tachyarrhythmias—most notably, atrial fibrillation and atrial flutter—in older individuals has previously been seen. Here, we present one of the first case series demonstrating a similar relationship between sinus node dysfunction and much rarer etiologies of tachyarrhythmia—that is, postural tachycardia syndrome and inappropriate sinus tachycardia. The exact pathological mechanisms behind these arrhythmias as well as the observation of concurrent nodal dysfunction are poorly understood. Here, we propose both potential mechanistic pathways as well as an initial treatment algorithm for sinus node dysfunction based upon the existing evidence.
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Affiliation(s)
- Paul R Harnish
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Pinang Shastri
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Blair P Grubb
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo, Toledo, OH, USA
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50
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Petracek LS, Suskauer SJ, Vickers RF, Patel NR, Violand RL, Swope RL, Rowe PC. Adolescent and Young Adult ME/CFS After Confirmed or Probable COVID-19. Front Med (Lausanne) 2021; 8:668944. [PMID: 33996867 PMCID: PMC8116546 DOI: 10.3389/fmed.2021.668944] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/29/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction: Fatigue is a common acute symptom following SARS-CoV-2 infection (COVID-19). The presence of persistent fatigue and impaired daily physical and cognitive function has led to speculation that like SARS-CoV-1 infection, COVID-19 will be followed by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Methods and Results: We describe three adolescent and young adult patients who had confirmed or probable COVID-19 infections early on during the pandemic and were referred for evaluation to the Chronic Fatigue Clinic at the Johns Hopkins Children's Center. All patients reported orthostatic intolerance symptoms within the first 2 weeks of illness, and 10-min passive standing tests were consistent with postural tachycardia syndrome. After 6 months of illness, all three patients met criteria for ME/CFS. Clinical features of interest included strong histories of allergies in all three patients, two of whom had elevations in plasma histamine. Each demonstrated limitations in symptom-free range of motion of the limbs and spine and two presented with pathological Hoffman reflexes. These comorbid features have been reported in adolescents and young adults with ME/CFS. Conclusion: ME/CFS can be triggered by COVID-19 in adolescents and young adults. Further work is needed to determine the pathogenesis of ME/CFS after COVID-19 and optimal methods of treating these patients. Our preliminary study calls attention to several comorbid features that deserve further attention as potential targets for intervention. These include neuromuscular limitations that could be treated with manual forms of therapy, orthostatic intolerance and POTS for which there are multiple medications and non-pharmacologic therapies, treatable allergic and mast cell phenomena, and neurologic abnormalities that may require specific treatment. Larger studies will need to ascertain the prevalence of these abnormalities.
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Affiliation(s)
- Lindsay S. Petracek
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
| | - Stacy J. Suskauer
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
- Departments of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
| | | | - Neel R. Patel
- Central Florida Heart Care, Maitland, FL, United States
| | | | - Renee L. Swope
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
| | - Peter C. Rowe
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
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