Does Postural Orthostatic Tachycardia Syndrome (POTS) exacerbate influenza symptoms?

Does POTS Make Flu Symptoms Worse?

Yes, POTS can worsen flu symptoms because viral infections trigger autonomic dysfunction and exacerbate the underlying pathophysiologic mechanisms of POTS, including hypovolemia, deconditioning, and sympathetic overactivity.

Evidence from Viral Infections and POTS

The relationship between viral infections and POTS is well-established and bidirectional:

• 42% of POTS cases are preceded by viral infections, demonstrating that viruses can trigger the syndrome 1
• Up to 40% of POTS patients report a viral upper respiratory or GI infection as the precipitating event to their symptoms 2
• Patients with pre-existing POTS experience significant worsening of baseline autonomic symptoms during acute viral infections, with 92.7% reporting symptom exacerbation during the active infection phase 3
• 68% of POTS patients experienced worsening dysautonomia symptoms for 1-6 months post-infection, and 73.2% required additional pharmacotherapy for symptom control 3

Mechanisms of Symptom Worsening

Viral infections like influenza worsen POTS through multiple pathways:

Autonomic Dysfunction Amplification

• Viral infections can cause direct toxic injury to the autonomic nervous system and trigger autoimmune responses that worsen autonomic regulation 4
• Inflammation and immune activation from viral illness compound the existing dysautonomia in POTS 1

Volume Depletion

• Viral illnesses cause dehydration through fever, decreased oral intake, and increased insensible losses, which critically worsens the hypovolemic component of POTS 1
• Reduced plasma volume from illness exacerbates the compensatory tachycardia that defines POTS 1

Deconditioning

• Bedrest and reduced activity during viral illness rapidly worsen cardiovascular deconditioning, which can occur after as little as 20 hours of bedrest 1
• This deconditioning reduces stroke volume and increases compensatory tachycardia, amplifying POTS symptoms 1

Clinical Manifestations During Viral Illness

POTS patients with concurrent viral infections typically experience:

• Worsening orthostatic intolerance with more severe dizziness, lightheadedness, and presyncope 3
• Increased tachycardia beyond baseline POTS levels 3
• Amplified fatigue and exercise intolerance 3
• Enhanced palpitations and tremor 2
• Prolonged recovery periods extending 1-6 months post-infection 3

Management During Viral Illness

Immediate Interventions

• Aggressively maintain hydration with 3 liters of water or electrolyte-balanced fluids daily, as dehydration from viral illness compounds POTS pathophysiology 1
• Increase salt intake to 5-10 grams (1-2 teaspoons) per day through liberalized dietary sodium to counteract volume depletion 1
• Avoid factors that worsen dehydration including alcohol, caffeine, large meals, and excessive heat exposure 1

Positional Strategies

• Use waist-high compression stockings to support central blood volume during illness 1
• Elevate the head of the bed with 4-6 inch blocks to help maintain plasma volume 1
• Minimize upright activity during acute illness to reduce orthostatic stress 1

Pharmacologic Adjustments

• Consider escalating existing POTS medications or adding therapies during acute viral illness, as 73.2% of patients required additional pharmacotherapy 3
• Low-dose beta-blockers (bisoprolol, metoprolol, propranolol) or nondihydropyridine calcium-channel blockers (diltiazem, verapamil) can be titrated up to control excessive tachycardia 1
• Fludrocortisone up to 0.2 mg at night combined with salt loading can increase blood volume, though monitor for hypokalemia 1
• Midodrine 2.5-10 mg with first dose before rising and last dose no later than 4 PM can help with orthostatic intolerance 1

Common Pitfalls

• Do not assume POTS symptoms will resolve quickly after viral illness clears—expect prolonged recovery of 1-6 months 3
• Do not allow complete bedrest during viral illness as this worsens deconditioning; maintain some recumbent activity when possible 1
• Do not discontinue POTS medications during viral illness—most patients need escalation, not reduction 3
• Recognize that patients may test positive for viral infections multiple times (27% in one study), requiring repeated vigilance 3