Postural orthostatic tachycardia syndrome in primary care: diagnosis, treatment and a case of African-American man presenting with POTS

THE UTILITY OF THE NORMAL THIN SECTION SKIN BIOPSY IN THE ASSESSMENT OF SYSTEMIC/EXTRACUTANEOUS DISEASE

BACKGROUND

Diseases reflective of multiorgan vascular injury of diverse etiology, peripheral nerve disease, dysautonomia syndromes and intravascular lymphoma malignancies may potentially exhibit abnormalities on a normal skin biopsy that may be instrumental in establishing a diagnosis.

MATERIALS AND METHODS

A retrospective review of our data base was conducted to uncover cases where a normal skin biopsy was performed to rule in or out certain systemic diseases such as complement driven thrombotic microvascular disease including atypical hemolytic uremic syndrome, post transplant thrombotic microangiopathy, and severe/critical COVID-19, systemic capillary leak syndrome, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) intravascular B cell lymphoma, dysautonomia syndromes and mast cell activation syndrome. Immunohistochemical stains were conducted inclu C5b-9, CD56, MXA, B and T cell markers.

RESULTS

There were expected patterns critical in establishing diagnosis based on evaluating certain parameters including assessing for increased C5b-9 microvascular deposition from the deltoid area(atypical hemolytic uremic syndrome, post-transplant thrombotic microangiopathy, catastrophic antiphospholipid antibody syndrome and severe/critical COVID-19), enhanced type I interferon signaling (systemic capillary leak syndrome), ultrastructural arteriopathic changes (CADASIL),lower extremity reduced cutaneous autonomic innervation (small fiber neuropathy and POTS), abdominal, thigh and buttock skin for the presence of intravascular lymphocytes on biopsy(intravascular B cell lymphoma), distinct structural changes in elastic fibers supportive of pseudoxanthoma elasticum and a higher than normal density of mast cells in the absence of other inflammatory cell types (mast cell activation syndrome).

CONCLUSION

The skin is a critical window for understanding disease, a concept well exemplified by the myriad of diseases that can be suggested by the microscopic and or ultrastructural examination of clinically normal skin, hence establishing the normal skin biopsy as an important tool for understanding extracutaneous disease.

Postural orthostatic tachycardia syndrome in a Thai male patient

Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous autonomic disorder. All patients have exaggerated tachycardia upon standing, but the pathophysiology may be diverse. We present a young adult Thai male with a chief complaint of palpitations while in an upright posture since childhood. The patient underwent a modified Ewing test battery which included standing test, deep breathing, and Valsalva maneuver. His heart rate increased more than 30 beats per minute (bpm) during repeated active stand tests (65 to 110 bpm and 77 to 108 bpm), while upright diastolic blood pressure increased more than 10 mmHg. Normal Valsalva ratio (2.01 and 1.86) and baseline heart rate variability (HFRRI = 4030.24 ms2 and 643.92 ms2) indicated intact vagal function. High low-frequency systolic blood pressure variability (LFSBP = 20.93 mmHg2), increased systolic blood pressure overshoot in phase IV of Valsalva (42 mmHg), and increased upright diastolic blood pressure indicated a hyperadrenergic state. In conclusion, the overall autonomic profile was compatible with hyperadrenergic POTS. Thus, we confirmed the first male POTS case reported in Thailand. We demonstrated the importance of autonomic function testing with continuous measurements to confirm POTS. There is a need for further research in POTS in Thailand.

Dysautonomia, Hypermobility Spectrum Disorders and Mast Cell Activation Syndrome as Migraine Comorbidities

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.

Gluten-free diet in postural orthostatic tachycardia syndrome (POTS)

OBJECTIVES

Postural orthostatic tachycardia syndrome (POTS) is a chronic disorder of the autonomic nervous system that is associated with orthostatic intolerance (OI) and gastrointestinal (GI) symptoms. We aimed to determine if a gluten-free diet (GFD) may be an effective treatment in patients with POTS.

METHODS

Patients with confirmed POTS and without celiac disease who followed GFD for  4 weeks retrospectively completed pre- and post- GFD COMPASS-31 questionnaires. Paired-samples t-tests were conducted to compare COMPASS-31 scores before and after adopting GFD.

RESULTS

All 20 patients (all females, age 16-62 years (mean age 33)), had POTS symptoms for 1-30 years (mean 10.8, SD  =  10.23 years). Eleven patients had co-morbid mast cell activation syndrome, and 8 had hypermobile Ehlers-Danlos syndrome. Pre-GFD COMPASS-31 scores (mean 57.8) were significantly higher than post-GFD scores (mean 38.2, t(19) = -8.92, p < 0.00001), with the largest improvement noted in the OI (p < 0.00001), vasomotor, (p  =  0.0034), and GI (p  =  0.0004) domains and with a mean reduction in total COMPASS-31 score by 33.9% after implementing GFD. All patients reported improved symptoms on GFD with mean self-assessed improvement of 50.5% (range 10-99%).

DISCUSSION

GFD may be effective in reducing the symptom burden in patients with POTS, particularly in the OI, vasomotor, and GI symptom domains. Large prospective studies are necessary to confirm whether GFD is an effective long-term treatment option for patients.