Murtaza Syed, MD
Fellow
SUNY Upstate
Syracuse, New York, United States
Johanna Mottram, MD
Resident Physician
SUNY Upstate Medical University
Syracuse, New York, United States
Jordan Adler, MD
Attending Physician
SUNY Upstate Medical University
Syracuse, New York, United States
A 62yo patient with history of incomplete tetraplegia due to traumatic SCI from fall while playing soccer in 1986 s/p C3-C6 decompression and fusion, neurogenic bladder, spasticity, atrial fibrillation, and BPH was admitted to inpatient rehabilitation after elective surgery C4-T4 fusion due to worsening left upper extremity weakness and impaired function for one month.
He contracted COVID-19 from a visitor and was treated symptomatically with increased fluid intake. He developed dizziness and significant orthostatic hypotension. The first episode of symptomatic hypotension with an SBP 70mmHg occurred on day nine after positive COVID test. Orthostatic vitals were positive. This was managed with encouraging continued oral fluid intake, compression stockings, and activity modification. He had another episode of orthostatic hypotension to 80s/60s on day 24 after testing positive. Metoprolol dose was halved. Tamsulosin was discontinued with improvement in symptoms.
Disruption of global circulatory function can lead to alteration in heart rate or blood pressure. This can result in lightheadedness, syncope, fatigue. Microvascular dysfunction can lead to headache, brain fog, orthostatic intolerance without hypotension.
Existing literature points towards POTS as most common cardiovascular autonomic dysfunction after COVID, with orthostatic hypotension more common in older patients. Pathophysiology of acquired OH in patients with covid is unclear. Current theories include peripheral autonomic neuropathy, hypovolemia, impaired vagal activity, reactive autoimmune inflammation from persistence of viral particles causing sustained immune response with microvascular and endothelial dysfunction.
Challenges in managing OH in patients with SCI include bladder catheterization management, skin management from compression stockings, and medication management for common comorbidities such as neurogenic bladder and neuropathic pain.
