Case report of long-term postural tachycardia syndrome in a patient after messenger RNA coronavirus disease-19 vaccination with mRNA-1273

Martin F Reiner; Dörthe Schmidt; Lukas Frischknecht; Frank Ruschitzka; Firat Duru; Ardan M Saguner

doi:10.1093/ehjcr/ytad390

Case report of long-term postural tachycardia syndrome in a patient after messenger RNA coronavirus disease-19 vaccination with mRNA-1273

Eur Heart J Case Rep. 2023 Aug 19;7(8):ytad390. doi: 10.1093/ehjcr/ytad390. eCollection 2023 Aug.

Authors

Martin F Reiner¹, Dörthe Schmidt¹, Lukas Frischknecht², Frank Ruschitzka^{3

4}, Firat Duru^{1

5}, Ardan M Saguner¹

Affiliations

¹ Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
² Department of Immunology, University Hospital Zurich, Zurich, Switzerland.
³ Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
⁴ Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
⁵ Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland.

Abstract

Background: Postural tachycardia syndrome (POTS) is characterized by orthostatic intolerance and heart rate increase in an upright position without orthostatic hypotension. It has been described after coronavirus disease-19 (COVID-19) as well as after COVID-19 vaccination.

Case summary: A 54-year-old female patient presented with a 9-months history of severe orthostatic intolerance since COVID-19 vaccination with messenger RNA (mRNA)-1273 (Spikevax, Moderna). Except for diet-controlled coeliac disease, the patient was healthy, had no allergies, and did not take regular medication. Tilt table testing revealed a significant heart rate increase to 168 bpm without orthostatic hypotension accompanied by light-headedness, nausea, and syncope, findings consistent with POTS. Potential underlying causes including anaemia, thyroid dysfunction, adrenal insufficiency, pheochromocytoma, (auto)-immune disease, chronic inflammation as well as neurological causes were ruled out. Echocardiography and cardiac stress magnetic resonance imaging (MRI) did not detect structural or functional heart disease or myocardial ischaemia. Forty-eight-hour-electrocardiogram (ECG) showed no tachycardias other than sinus tachycardia. Finally, genomic analysis did not detect an inherited arrhythmia syndrome. Serologic analysis revealed adequate immune response to mRNA-1273 vaccination without signs of previous severe acute respiratory syndrome-coronavirus-2 infection. While ivabradine was not tolerated and metoprolol extended release only slightly improved symptoms, physical exercise reduced orthostatic intolerance moderately. At a 5-months follow-up, the patient remained dependant on assistance for activities of daily living.

Discussion: The temporal association of POTS with the COVID-19 vaccination in a previously healthy patient and the lack of evidence of an alternative aetiology suggests COVID-19 vaccination is the potential cause of POTS in this patient. To our knowledge, this is the first case reporting severe, long-term, and treatment-refractory POTS following COVID-19 vaccination with mRNA1273.

Keywords: Case report; Coronavirus disease-19 (COVID-19); Moderna; Postural tachycardia syndrome (POTS); Spikevax; mRNA vaccination; mRNA-1273.

Publication types

Case Reports