Impact of Covid-19 Infection on Baseline Autonomic Symptoms in Patients with Pre-Existing Postural Tachycardia Syndrome and Orthostatic Intolerance

Background: Recently there have been several published case series of some survivors of COVID-19 infection left with chronic symptoms of autonomic dysfunction (AD) with features of orthostatic tachycardia syndrome (POTS). However, the impact of this viral illness on the underlying autonomic symptoms has not been studied in the patient population who have a pre-existing POTS diagnosis and are receiving treatment. Objective(s): So far, the impact of this viral illness on the underlying autonomic symptoms has not been studied in patients with a pre-existing POTS diagnosis and receiving treatment. Our study aims to report the impact of a COVID-19 infection on these patient populations, both during the acute phase of the disease and post-recovery. Method(s): Our Institution Review Board (IRB) approval was obtained to access charts of the study subjects. Basic demographic and diagnosis details including the age, sex, prominent symptoms, duration of POTS diagnosis, medications, associated autonomic disease, and medication regimen were obtained from the retrospective chart review. Additional information regarding COVID-19 infection, course of illness, need for hospitalization, worsening of POTS symptoms, need for ED visits, improvement with the escalation of therapy, the type of persisting symptoms, and vaccination status were obtained from both chart review and details from the patients during the scheduled office visit. Result(s): A total of 49 patients were studied. About 42 patients (82 %) had the alpha-variant infection before the vaccines were available. 28% (14 patients) of them had tested positive for infection more than once (i.e infection with alpha, delta, or omicron variant). About 38 (92.7%) of them reported having worsening of their baseline POTS symptoms during the active infection phase. About 28 patients (57 %) 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. Conclusion(s): Of subjects 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. The majority of them had recovered within 6 months of therapy. From our observation, it is evident that the COVID-19 infection exacerbates the underlying symptoms in patients with established POTS disease.Copyright © 2023

Autonomic Dysfunction after Covid-19 Immunization - Case Report

Background: The infection caused by the SARS-CoV-2 continues affecting millions of people worldwide and vaccines to prevent the coronavirus disease (COVID-19) are considered the most promising approach for curbing the pandemic. Otherwise, cardiovascular and neurological complications associated with the vaccines were speculated and some few case reports were published. Objective(s): We describe a case of postural orthostatic tachycardia syndrome (POTS) after viral vector COVID-19 vaccination and the possible autoimmune process of the syndrome. Method(s): A 35-year-old female, without previous symptoms or comorbidities, developed intermittent palpitation, intense fatigue and dyspnea, compromising her daily activities, triggered by upright position, seven days following the second dose of the Oxford vaccine. Physical examination was normal, except for a heart rate (HR) increase of 33 beats/min from supine to standing position, with no significant change in blood pressure and reproduction of symptoms. Result(s): A 24-hour Holter monitoring revealed episodes of spontaneous sinus tachycardia correlated with palpitation and fatigue. Extensive diagnostic investigations excluded primary cardiac, endocrine, infectious and rheumatologic etiologies. The patient underwent an autonomic function test which demonstrated normal baroreflex sensitivity, as well as normal cardiovagal and adrenergic scores. Head-up tilt test showed persistent orthostatic tachycardia (HR increase from a medium of 84 beats/min in supine position to 126 beats/min during upright tilt), without hypotension, consistent with the diagnostic criteria for POTS. According to the current guidelines, general behavior recommendations, pharmacotherapy with low dose of propranolol associated with the autonomic rehabilitation were oriented. Along three months of follow-up, the patient reported a gradually improvement in her symptoms. Conclusion(s): POTS is a heterogeneous disorder of the autonomic nervous system characterized by orthostatic tachycardia associated with symptoms of orthostatic intolerance. Although the physiopathology of COVID-19 vaccine and autonomic disorders remains speculative, autoimmune response is one of the possible mechanisms. Based on clinic presentation, the time frame of symptom onset is consistent with other well-known post-vaccination syndromes, which may be an indicator of an autoimmune process induced by immunization. Further studies are needed to assess causal relationship between immunization and autonomic dysfunction.Copyright © 2023

Ndegree35 - Neurophysiology solving the vomiting dilemma

Objectives: Post Covid severe vomiting together with proximal muscle weakness is a misleading combination, this describes a rare but definite clinical association between myasthenia gravis and autonomic failure and strengthen the concept that subacute autonomic neuropathy is an autoimmune disorder. Content: A 39 ys old adult female presented with postCovid severe vomiting for one year with 40 kgs loss Upper gastrointestinal endoscopy revealed gastric dilatation associated with eosophageal and gastric stasis and hypertrophic pyloric stenosis. the gastroenterologist sought neurological consultation for the coexisting unexplained limb weakness before operation EMG & NCV was all normal except instability of the MUAPs Slow rate Repetitive supramaximal stimulation (RNS) revealed significant decremental response with no significant high rate stimulation incrementation Chest CT revealed an anterior mediastinal mass Surprisingly, She had an old CT during the covid infection that showed the same mass. Thoracoscopic resection revealed type B1 thymoma Following tumor resection, the patient improved gradually, Few months later endoscopy revealed a normal stomach with strong peristaltic waves and the patient was symptom free Infections are recognized to trigger exacerbations and crisis in MG Dysautonomia is not a commonly recognized feature of myasthenia gravis, but there have been rare reports of myasthenia gravis coexisting with autonomic failure, usually in association with thymoma. The autonomic dysfunction can present as isolated gastroparesis these observations support a rare but definite clinical association between myasthenia gravis and autonomic failure Neurophysiology could reveal undiagnosed MG with thymoma causing autonomic dysfunction in the form of gastroparesis and agonizing vomiting. Keywords: Myasthenia gravis;Gastroparesis;Autonomic failure;Thymoma;PostCovid vomiting. French language not detected for EMBFRA articles source xmlCopyright © 2023

Mechanisms of Atrial Fibrillation in Covid-19

Atrial fibrillation (AF) is the most frequent form of cardiac arrhythmia in COVID-19 infected patients. The occurrence of AF paroxysms is often associated with the acute period of infection in time. At the same time, the pathophysiological mechanisms of the occurrence of AF associated with COVID-19 remain insufficiently studied. The review considers the available literature data on the influence of factors such as reduced availability of angiotensin-converting enzyme 2 receptors, interaction of the virus with the cluster of differentiation 147 and sialic acid, increased inflammatory signaling, "cytokine storm", direct viral damage to the endothelium, electrolyte and acid-alkaline balance in the acute phase of severe illness and increased sympathetic activity.Copyright © Autors 2023.

Cognitive and psychological consequences of moderate-tosevere COVID-19 pneumonia: associations with clinical variables in convalescent patients without previous comorbidities

Background: Cognitive impairment has been reported in the aftermath of severe acute respiratory syndrome due to coronavirus 2 (SARS-CoV-2) infection. We investigated the possible association between cognitive impairment and the main clinical and functional variables in a cohort of convalescent COVID-19 patients without premorbid diseases. Method(s): Convalescent COVID-19 patients referring to of a post-acute care facility for pulmonary rehabilitation were consecutively screened for inclusion. All the enrolled patients completed standardized tests to assess cognitive functions, features of psychological distress such as anxiety, depression, post-traumatic stress disorder (PTSD) and quality of life, and cardiac and pulmonary functional status. Result(s): The 63 enrolled patients (mean age 59.82+/-10.78, male = 47) showed a high rate of clinically relevant depressive symptoms (76.2%) and anxiety (55.5%), and a high prevalence of PTSD (44.4%). About half of the total sample showed reduced cognitive efficiency (44.4%). Most impaired cognitive domains were verbal fluency and longterm spatial memory. The level of cognitive impairment showed a direct correlation with the alteration of blood pressure circadian rhythm (rho=. 410, p=.002) and an inverse association with PaO2 (rho= -.264, p=. 03) and DLCO% values (rho= -.252, p=. 02). Conclusion(s): Our findings indicated a possible association between the reduced cognitive efficiency after COVID-19 and some cardiological and pneumological variables, including some indirect measures of a residual autonomic disorder, such as the presence of an altered BP circadian rhythm.

COVID-19-INDUCED POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Postural orthostatic tachycardia syndrome (POTS) is one of the most common autonomic disorders (1). POTS is diagnosed by increasing heart rate by 30 bpm on more, within the first 10 minutes of standing, without orthostatic hypotension (2). Associated debilitating symptoms are lightheadedness, fainting, tremor, orthostatic intolerance, and tachycardia (2). Viral infections such as HIV, hepatitis C, mumps, Epstein bar virus, and influenza have been commonly reported with POTS syndrome (3 ). We are presenting a rare case of COVID-19 induced POTS. CASE PRESENTATION: 38-year-old presented to the hospital with the chief complaint of shortness of breath chest tightness. Her past medical history was significant for COVID-19 infection two weeks before presentation. On arrival patient's vitals were within normal limits. Her physical examination was unremarkable. Laboratory investigations, including complete blood count, thyroid function test, and comprehensive metabolic profile, were unremarkable. Chest x-ray, CT angiogram, and echocardiogram were unremarkable for any consolidation, pulmonary embolism, and congestive heart failure. Orthostatic vitals were obtained, showing that the patient's heart rate increased from 90 beats/minute to 140 beats/minute, from supine to standing. This patient was diagnosed with COVID-19 induced POTS, given she was meeting the criteria of POTS and no other reason was found for postural orthostatic tachycardia. She was managed conservatively with hydration, and the patient was also instructed about yoga therapy. She was discharged home with a cardiology follow-up. DISCUSSION: COVID-19 induced POTS is a relatively new entity that most commonly affect female, and the estimated prevalence is around is 17 per 100,000 patients (3). It has been reported that 10% of the patient who tests positive for COVID-19 infection remains unwell beyond three weeks after recovery from the infection (2). For some of those patients, POTS may be the cause of their symptoms. The exact pathophysiology for COVID-19 induced POTS is poorly understood and may includes peripheral neuropathy, baroreceptor dysfunction, hypovolemia, and increased serum norepinephrine (2). Nonpharmacological treatment includes increasing fluid consumption of 2 to 3 L of water per day, lower limb compression stockings, and regular exercise (2). The commonly off-label pharmacological treatment include ivabradine, fludrocortisone, midodrine, and beta-blockers (2). CONCLUSIONS: POTS is a new and under-recognized entity. The clinician should have a high suspicion of POTS syndrome in a patient with a history of recent or remote COVID-19 infection presenting with orthostatic symptoms. Timely diagnosis is essential to prevent the morbidity associated with debilitating symptoms. Reference #1: Blitshteyn S & Whitelaw S. Postural Orthostatic Tachycardia Syndrome (POTS) and Other Autonomic Disorders After COVID-19 Infection: A Case Series of 20 Patients. Immunol Res. 2021;69(2):205-11. Reference #2: Jenna Stephanie O'Sullivan, Andrew Lyne, Carl J Vaughan. COVID-19-Induced Postural Orthostatic Tachycardia Syndrome Treated with Ivabradine. BMJ Case Reports CP. 2021;14(6):e243585. Reference #3: Sujana Reddy, Satvik Reddy, Manish Arora. A Case of Postural Orthostatic Tachycardia Syndrome Secondary to the Messenger RNA COVID-19 Vaccine. Cureus. 2021;13(5). DISCLOSURES: No relevant relationships by Arshan Khan

Heart Rate Variability And Cardio-Renal Outcomes In Patients With Novel Covid 19 Infection

Studies have shown that SARS-CoV2 can infect the vagal nerve and its connections to the brain stem. This neuronal involvement is seen mostly in the delayed inflammatory phase. It is associated with autonomic nervous system dysfunction, resulting in decreased respiratory ventilation and impaired blood pressure as well as heart rate regulation. The dysautonomia seen in SARSCoV-2 infection can be measured, and heart rate variability (HRV) measurement is one method. Our study explores the relationship between autonomic dysfunction and mortality in patients with COVID- 19 using HRV measurement. In a prospective design, data of consecutive patients with SARS-CoV-2 positive infection admitted to Banner university of Arizona, Tucson, and whose telemetry information was available was collected between August 2020 to November 2021. We attempted to use the telemetry data to measure diurnal heart rate variation by obtaining mean average hourly heart rates, divided into 12-hour day/night periods. The primary outcome measure was mortality. The secondary outcome measured includes incidence of acute kidney injury, transfer to ICU, need for mechanical ventilation, and live discharge from hospital. 334 patients were included in the study. The baseline demographic characteristics, medical history, radiological data, laboratory data, details of medications, and hospital course were reported. Diseases associated with an autonomic dysfunction like diabetes mellitus, chronic renal failure, a history of alcohol abuse, clinical evidence of autonomic neuropathy, or a recent myocardial infarction, documented constrictive or hypertrophic cardiomyopathy, sustained non-sinus dysrhythmias, atrioventricular conduction defects will be excluded in the final analysis. Mortality was high in patients with lower heart rate variability. Compared with survivors, non-survivors were older, were less frequently women, had a higher prevalence of diabetes mellitus, longer stay in the hospital, received an organ transplant, smoking, and higher level of calcitonin. Lower heart rate variability was associated with a higher incidence of acute kidney injury, need for mechanical ventilation, and need for ECMO. This study suggests that analysis of the variability of heart rate may have prognostic implications in patients with COVID19.

Autonomic dysfunction following COVID-19 infection: an early experience

Objective: We present an early systematic analysis of autonomic dysfunction following COVID19 to provide initial insights into the spectrum of this condition. Background: Post-COVID-19 syndrome is a poorly understood aspect of the current pandemic, with clinical features that overlap with symptoms of autonomic/small fiber dysfunction. Design/Methods: We conducted a retrospective review of all patients with confirmed history of COVID-19 infection referred for autonomic testing for symptoms concerning for para-/postinfectious autonomic dysfunction at Mayo Clinic Rochester or Jacksonville between March 2020 and January 2021. Results: We identified 27 patients fulfilling the search criteria. Symptoms developed between 0 and 122 days following the acute infection and included lightheadedness (93%), orthostatic headache (22%), syncope (11%), hyperhidrosis (11%), and burning pain (11%). Sudomotor function was abnormal in 36%, cardiovagal function in 27%, and cardiovascular adrenergic function in 7%. The most common clinical scenario was orthostatic symptoms without tachycardia or hypotension (41%);22% of patients fulfilled the criteria for postural tachycardia syndrome (POTS), and 11% had borderline findings to support orthostatic intolerance. One patient each was diagnosed with autoimmune autonomic ganglionopathy, inappropriate sinus tachycardia, vasodepressor syncope, cough/vasovagal syncope, exacerbation of preexisting orthostatic hypotension, exacerbation of sensory and autonomic neuropathy, and exacerbation of small fiber neuropathy. Conclusions: Abnormalities on autonomic testing were seen in the majority of patients but were mild in most cases. The most common finding was orthostatic intolerance, often without objective hemodynamic abnormalities on testing. Unmasking/exacerbation of preexisting conditions was seen. The temporal association between infection and autonomic symptoms implies a causal relationship, which however cannot be proven by this study.

Hospital-based Observational Study of Neurological Disordersin Patients Recently Vaccinated with COVID-19 mRNA Vaccines

Objective: To describe the spectrum of acute neurological disorders among hospitalized patients who recently received COVID-19 mRNA vaccination. Background: The unprecedented pace of COVID-19 vaccine development, use of novel mRNA technology and large-scale vaccination programs have engendered concerns of adverse events following immunization. Design/Methods: We performed a multi-centre prospective observational study in 7 public acute hospitals. Hospitalized patients who were referred for neurological complaints and had COVID-19 mRNA vaccines, BNT162b2 and mRNA-1273, in the last 6 weeks were classified into central nervous system(CNS) syndromes, cerebrovascular disorders, peripheral nervous system(PNS) disorders, autonomic nervous system(ANS) disorders and immunization stressrelated responses(ISRR). To contextualize our findings, data from National Immunization Registry was probed for the total number and demographic of individuals vaccinated in the corresponding period. Results: From 30 December 2020 to 20 April 2021, 1,398,074 persons (median age 59 years, 54.5% males) received COVID-19 mRNA vaccine (86.7% BNT162b2, 13.3% mRNA-1273);915,344 (65.5%) completed 2 doses. Four hundred and fifty-seven (0.03%) patients were referred for neurological complaints [median age 67 years, 61.5% males;95.8% received BNT162b2 and 4.2% mRNA-1273];classified into 73 (16.0%) CNS syndromes, 286 (62.6%) cerebrovascular disorders, 59 (12.9%) PNS disorders, 0 ANS disorders and 39 (8.5%) ISRRs. Twenty-seven had cranial mononeuropathy, 11 of whom had Bell's palsy. Of 33 patients with seizures, only 4 were unprovoked and occurred within 2 weeks of vaccination. All strokes occurred among individuals with pre-existing cardiovascular risk factors. We recorded 2 cases of cerebral venous thrombosis;none associated with thrombocytopenia. Five had mild flares of immune-mediated diseases. Conclusions: Our observational study does not establish causality of the described disorders to vaccines and is limited by lack of baseline incidence data of several conditions. Nevertheless, we did not observe any obvious signal of serious neurological morbidity associated with mRNA vaccination. The benefits of COVID-19 vaccination outweigh concerns over neurological adverse events.

COVID-Long Haulers Can Develop POTS (Postural Orthostatic Tachycardia Syndrome) with Small Fiber Neuropathy and Abnormal Autonomic Testing

Objective: A substantial number of COVID long-haulers have developed POTS, which warrants further investigation. This study is intended as a first look at a new and growing patient population that is bringing greater attention to the prevalent autonomic disease of POTS. Background: POTS (Postural Orthostatic Tachycardia Syndrome) is a disorder of autonomic dysregulation involving overactive compensation for postural blood pressure changes. This debilitating syndrome can be associated with small fiber neuropathy and a broad spectrum of autonomic symptoms including palpitations, changes in sweating, and gastrointestinal problems like constipation. Respiratory and gastrointestinal viruses have been known to cause onset of POTS pathophysiology. In approximately 10% of COVID cases, patients experience long-term health effects after the conclusion of their COVID infection. These patients are called COVID “long-haulers.” Design/Methods: We conducted a chart review of 25 Cleveland Clinic post-COVID POTS patients who are mostly female (84%) to learn about this patient population's distribution of top symptoms, comorbidities, autonomic testing, and autonomic questionnaire scores. Top three symptoms were determined based on the physician's note from the patients' initial visit to the Cleveland Clinic Neurology Department. Results: Our chart review revealed a high occurrence of excitatory comorbidities such as chronic migraine (44%) and irritable bowel syndrome (24%). In addition, when assessing patients' top three POTS symptoms, we found that palpitations, fatigue, and dyspnea were affecting patients most. As with POTS in general, autonomic testing outside of tilt table testing (85.7%) shows variable results with QSART (50%), skin punch biopsy (37.5%), deep breathing (14.3%), and Valsalva testing (0%) all showing positivity rates of 50% or less for our patient sample. Conclusions: Post-COVID POTS could be an excitatory process with hyperadrenergic signaling based on the symptoms and comorbidities. We hope that this chart review will be the launching point for future studies aimed at achieving greater understanding of the post-COVID POTS phenomenon.

Happy hypoxia in COVID-19 patients associated with hypoxic ventilatory depression

Objective: Acute exposure to hypoxia generally increase the ventilation. However, some of COVID-19 patients who suffer from pneumonia are characterized by hypoxic ventilatory depression with loss of dyspnea which is called as happy hypoxia. This report describes the background and the clinical issues of happy hypoxia. Methods: The mechanisms to increase ventilation and dyspnea under hypoxia are explained. Further, clinical issues and characteristics in COVID-19 are reviewed. Results: Genetic factors are definitely concerned with chemosensitivity to hypoxia. Further disease factors including COVID-19 infection could influence the attenuation of the chemosensitivity. This can be attributed to either ventilatory depression due to the modulation of metabolic substrate, adenosine in the brain, or autonomic neuropathy including the dysfunction of the carotid body. Conclusions: COVID-19 patients must be carefully treated and/or monitored to avoid hypoxic ventilator depression. The clinical application of aminophylline will be an issue to be considered.

Understanding and Managing Postural Orthostatic Tachycardia Syndrome

Postural orthostatic tachycardia syndrome (POTS) is a disorder of the autonomic nervous system that is often misunderstood and is typically seen in younger women. Emerging data suggest an association between coronavirus disease 2019 and POTS. Given the rise in POTS cases, it is imperative that clinicians and other healthcare professionals better understand this condition. Although several nonpharmacologic and pharmacologic treatments exist for patients with POTS, none are currently FDA-approved. As therapeutics experts and the most accessible members of the healthcare team, pharmacists play a pivotal role in optimizing treatment outcomes by directing patients to further evaluate symptoms and in proposing therapeutics to other healthcare professionals.

Autonomic neuropathy as post-acute sequela of SARS-CoV-2 infection: a case report.

Symptoms of autonomic dysfunction, particularly those of orthostatic intolerance, continue to represent a major component of the currently recognized post-acute sequelae of SARS-CoV-2 infections. Different pathophysiologic mechanisms can be involved in the development of orthostatic intolerance including hypovolemia due to gastrointestinal dysfunction, fatigue-associated deconditioning, and hyperadrenergic state due to pandemic-related anxiety. Additionally, there has been a well-established association of a common primary autonomic disorder like postural orthostatic tachycardia syndrome, a subtype of orthostatic intolerance, with antecedent viral infections. Here we report a case of neuropathic type postural orthostatic tachycardia syndrome as a form of autonomic neuropathy that developed following COVID-19 infection.

Cardiovascular autonomic disorders and work ability: A focus on post-acute Covid19 syndrome

A relationship between the autonomic nervous system and work ability has been recently described in autonomic disorders, i.e., Postural Orthostatic Tachycardia Syndrome (POTS). It is unknown whether COVID19 may induce a post-acute viral syndrome potentially affecting the autonomic nervous systems. No data are available on work ability and time of return to work of patients after Covid19. Forty patients (age 53±9 years) admitted to Humanitas Research Hospital during the 2nd and 3rd outbreaks in Italy were consecutively enrolled at the time of their hospital discharge (T0). Work ability and autonomic symptoms were assessed at T0, 1 month (T1) and 3 months (T2) after hospital discharge by the Work Ability Index (WAI, 7 domains, 0-49) and by the Composite Autonomic Symptom Score (COMPASS31Total Score, 0-100;CTS). CTS > 16.4 reflects an initial autonomic dysfunction. At T0, the patients were asked to retrospectively complete the additional questionnaires to assess their work ability and autonomic symptoms before COVID19 (PRE). At PRE, the patients’ WAI was 42.3±5.4, corresponding to “good work ability” and the CTS was 10.7±11.9. At T1, WAI was lower (35.9±6.5;p<0.0001), and CTS was higher (20.4±17.4, p<0.0001) compared to PRE. At T2, WAI was still lower compared to PRE (38.9±6.4;p <0.001). At T1 and T2, the patients who returned to their previous work were 95% and 97%, respectively. Post-acute COVID19 are characterized by an autonomic dysfunction, like what is observed in POTS. This post-viral autonomic syndrome reduced patients’ work ability and delayed their return to work.

Special Session 4 Stress, sleep, cardiovascular autonomic disorders and health promotion

Session introduction Three studies involving over 4000 workers demonstrate that sleep quality is a significant predictor of metabolic syndrome. A review study indicates how sleep problems can alter the autonomic nervous system function, so increasing the cardiovascular risk. A Polish study shows the existence of adaptation mechanisms to night work in truck drivers, which limit the effect of sleep on the autonomic nervous system. An Italian study demonstrates that post-acute COVID19 patients often show an autonomic dysfunction, which impairs their work ability and obstacles their return to work. Finally, a review indicates that COVID19 disease is associated with sleep problems. All authors underline the importance of health promotion interventions in the workplace.

COVID-19 Dysautonomia.

Objective: To report a case series of dysautonomia associated with COVID-19 infection. Methods: This is a retrospective review of patients evaluated in the autonomic clinic at our institution with suspected signs and symptoms of dysautonomia who underwent formal evaluation, including autonomic testing. Results: Six patients were identified with signs and symptoms suggestive of dysautonomia who underwent autonomic testing. All patients had symptoms typical of COVID-19 infection, though none were hospitalized for these or other symptoms. All patients reported symptoms of postural lightheadedness and near-syncope, fatigue, and activity intolerance. Five patients reported the onset of autonomic symptoms concomitant with other COVID-19 symptoms, with the other patient reporting symptom onset 6 weeks following initial COVID-19 symptoms. Autonomic testing demonstrated an excessive postural tachycardia in 4 patients, a hypertensive response with head-up tilt in 3 patients, orthostatic hypotension in 1 patient, and sudomotor impairment in 1 of the patients with excessive postural tachycardia. Conclusions: We present clinical features and results of autonomic testing in 6 patients with a history COVID-19 infection. While all patients reported typical features of orthostatic intolerance, fatigue, and activity intolerance, the results of autonomic testing were heterogenous, with orthostatic hypotension in 1 patient, excessive postural tachycardia typical of postural tachycardia syndrome in 4 patients, and postural hypertension in 3 patients.

Pupil responses in patients with COVID-19.

AIM: To compare pupillary responses in patients with Coronavirus disease-2019 (COVID-19) during active infection and at 3rd months post-infection. METHODS: This study included 58 COVID-19 cases (mean age 47.23 ± 1.1 years). The scotopic, mesopic and photopic diameters were noted. Pupil diameters were noted at the 0, 1st, 2nd, 4th, 6th, 8th, and 10th seconds in reflex pupil dilation after the termination of a light. The average dilation speed was calculated at the 1st, 2nd, 4th, 6th, 8th, and 10th seconds. Pupil responses measured during COVID-19 infection and 3 months later were compared. RESULTS: The mean scotopic and mesopic pupil diameter value of during COVID-19 infection was found lower than the 3rd month post-infection. (p = 0.001, p = 0.023; respectively). No statistically significant difference was found in the mean photopic pupil diameter and the mean pupil diameter at 0 s between measurements (p > 0.05, p = 0.734; respectively). The mean pupil diameter was significantly lower during COVID-19 infection at the 1st, 2nd, 4th, 6th, 8th and 10th seconds (p < 0.01, for each). The average dilation speed measurements at every second measured were lower in during COVID-19 infection than the 3rd months later (p = 0.001; p < 0.01 for each). CONCLUSIONS: Pupil responses were found significantly different in COVID-19 cases when compared with the measurements taken three months later.