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\begin{document}

\title{Rapid gastric emptying as cause of gastrointestinal symptoms in
dysautonomia in a post-covid patient}



\author[1]{Rachel Welbel}%
\author[2]{Douglas Wang}%
\affil[1]{Advocate Christ Medical Center}%
\affil[2]{Rosalind Franklin University of Medicine and Science Chicago Medical School}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\begin{abstract}
Covid 19 infection and its subsequent post-viral sequelae (long-Covid)
has been associated with a range of clinical symptoms, including the
more recently recognized autonomic nervous system
dysfunction/orthostatic intolerance. Included in the autonomic nervous
system dysfunction spectrum includes non-cardiovascular symptoms
specifically gastrointestinal symptoms. We present a case of a
long-Covid patient with debilitating symptoms consistent with autonomic
dysfunction and gastrointestinal symptoms. We highlight the difficulty
of diagnosis and management of this patient and the importance of
awareness of presentation to not delay care in this complicated patient
population.%
\end{abstract}%



\sloppy


Title: Rapid gastric emptying as cause of gastrointestinal symptoms in
dysautonomia in a post-covid patient

Abstract: Covid 19 infection and its subsequent post-viral sequelae
(long-Covid) has been associated with a range of clinical symptoms,
including the more recently recognized autonomic nervous system
dysfunction/orthostatic intolerance. Included in the autonomic nervous
system dysfunction spectrum includes non-cardiovascular symptoms
specifically gastrointestinal symptoms. We present a case of a
long-Covid patient with debilitating symptoms consistent with autonomic
dysfunction and gastrointestinal symptoms. We highlight the difficulty
of diagnosis and management of this patient and the importance of
awareness of presentation to not delay care in this complicated patient
population.

Authors:

Rachel Welbel, MD, MS

Advocate Aurora Health, Oak Lawn, IL, USA

Douglas Wang

Rosalind Franklin University of Medicine and Science, North Chicago, IL,
USA

Introduction:~The SARS-CoV-2 virus, more commonly known as Coronavirus
2019 (COVID-19), and its subsequent post-viral sequelae (long-Covid) is
associated with a range of clinical symptoms, specifically autonomic
nervous system dysfunction/orthostatic intolerance. These syndromes
include orthostatic hypotension (OH), vasovagal syncope (VVS) and
postural orthostatic tachycardia syndrome (POTS) \textsuperscript{1,2}.
There is ongoing investigation of the pathophysiology, but it is thought
to be due to virus or immune-mediated disruption of the autonomic
nervous system.\textsuperscript{1} A case series of 20 patients revealed
that new-onset POTS can occur after COVID-19 in previously healthy
patients who experience persistent neurological and cardiovascular
symptoms after the resolution of the acute infection\textsuperscript{3}.

POTS is characterized by lightheadedness, dizziness, blurred or fading
vision, generalized weakness, fatigue, palpitations, mental clouding,
anxiety, nausea, dyspnea, and headache\textsuperscript{4}. Additionally,
gastrointestinal symptoms such as rapid gastric emptying are also common
in POTS patients\textsuperscript{4}.

According to researchers, nausea and abdominal pain are the most
frequent non-cardiovascular symptoms among POTS patients, with a
prevalence of 69\% in six studies involving 352
patients\textsuperscript{5}. Mehr et al. reported evidence of abnormal
gastric motility, with rapid gastric emptying occurring in 43\% of
cases. Another study examining 163 POTS patients with GI symptoms
revealed that 78 (48\%) had rapid gastric emptying\textsuperscript{6}.
However, to our knowledge, there are no studies to date that found an
association between rapid gastric emptying and dysautonomia in a
post-covid patient. In this case report, we present the clinical
findings, diagnostic results, treatments, differential diagnoses, and
recommendations for a post-COVID patient with dysautonomia and rapid
gastric emptying with the aim to highlight the diagnostic difficulties
and importance of early awareness.

Case description: A 52 year old male with a past medical history of
asthma presented to the Long-Covid clinic in April 2022. He tested
positive for Covid-19 in January 2022. He received the J\&J Booster in
May 2021. He presented to his primary care provider (PCP) just after
testing positive with shortness of breath, low grade fever, body aches,
fatigue, chest tightness and vomiting. He was subsequently sent to the
emergency department (ED) for escalation of care. ED work-up revealed a
normal chest x-ray, EKG, BMP and CBC. He was treated with IV fluids,
Tylenol, Zofran and discharged home with prednisone 50mg daily x 5 days
and an albuterol inhaler.

He continued to see his PCP for lingering symptoms which included
diarrhea, cough and fatigue. Treatments included Z-pak, Zofran, and
Imodium. He was then referred to the Long-Covid clinic. In this clinic
he was seen by a pulmonologist and a physiatrist. Initial labs were
significant for ESR: 36 and Vitamin D: 9.0. He had a negative ANA and
normal TSH. His complaints consisted of fatigue, tachycardia, muscle and
joint pain, diarrhea, insomnia and brain fog. He completed a sleep study
which showed sleep apnea. He was referred to physical therapy and speech
therapy. Autonomic dysfunction/POTs remained on the differential but the
focus at that time was on the fatigue and brain fog which were the most
debilitating symptoms.

For his gastrointestinal (GI) symptoms, he was referred to
gastroenterology who completed a colonoscopy and EGD in November 2022
which showed sigmoid diverticulosis and erosive esophagitis with a
nonobstructive Schatzki ring, gastritis, respectively.~ He was started
on pantoprazole 40mg daily for the latter. He continued to have
significant tachycardia and fatigue and was unable to be upright for
prolonged periods of time. More conservative measures for
POTS/dysautonomia including increased salt and water intake were
prescribed, but given his continued diarrhea and abdominal symptoms it
was difficult for him to be compliant with the regimen. He was then
started on Mestinon 30mg BID which caused severe constipation and
abdominal pain, despite improvements in tachycardia. He was then tapered
off the Mestinon which relieved those symptoms. At this time a gastric
emptying study was ordered, which revealed accelerated gastric emptying.
He was started on Rifaximin 550mg TID for 2 weeks and simethicone daily
after discussion with gastroenterology with no relief in symptoms. HbA1C
was ordered and was normal. He was then started on hyoscyamine 0.125mg
every 6 hours~ for relief in symptoms and 3 sessions of IV fluids for
dehydration and POTs. He reported some relief in symptoms with the
above, so this plan was continued with an increase in hycoasmine dose to
0.25mg every 6 hours and he is awaiting follow-up.

Discussion: This case highlights the need for multi-specialty care in
the long-covid population and the difficulties of managing these
patients. For the general gastroenterologist, management of rapid
gastric emptying in a dysautonomia patient is relatively unknown.
Further, for the general physiatrist, severe GI symptoms in the long
covid population was seen less frequently and it wasn't until reviewing
literature that the connection between rapid gastric emptying and
dysautonomia was made. Also, because this patient's symptoms were
multiple and most were debilitating, it presented a clinical challenge
for what treatment regimen to begin with. The patient's symptoms also
fluctuated throughout his time in the clinic, which is also very common
in the dysautonomia population.

Conclusion: Awareness of all possible symptoms in the dysautonomia
population are key to decreasing the length of time of patients'
suffering. In this case, rapid gastric emptying from autonomic
dysfunction secondary to long-covid is the likely etiology of his
diarrhea, but it took approximately one year in the long-covid clinic to
recognize this. While long-covid symptoms and management remain
challenging for most medical providers, awareness of etiologies of each
symptom, will aid in patient recovery and improve quality of life.

\begin{enumerate}
\tightlist
\item
  Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D,
  Sutton R, Lim PB. Autonomic dysfunction in 'long COVID': rationale,
  physiology and management strategies. Clin Med (Lond). 2021
  Jan;21(1):e63-e67. doi: 10.7861/clinmed.2020-0896. Epub 2020 Nov 26.
  PMID: 33243837; PMCID: PMC7850225.
\item
  Dotan, A., David, P., Arnheim, D., \& Shoenfeld, Y. (2022). The
  autonomic aspects of the post-COVID19 syndrome. \emph{Autoimmunity
  Reviews}, \emph{21}(5), 103071.
  https://doi.org/10.1016/j.autrev.2022.103071
\item
  Blitshteyn, S., \& Whitelaw, S. (2021). Postural orthostatic
  tachycardia syndrome (POTS) and other autonomic disorders after
  COVID-19 infection: A case series of 20 patients. \emph{Immunologic
  Research}, \emph{69}(2), 205--211.
  https://doi.org/10.1007/s12026-021-09185-5
\item
  Benarroch, E. E. (2012). Postural Tachycardia Syndrome: A
  Heterogeneous and Multifactorial Disorder. \emph{Mayo Clinic
  Proceedings} , \emph{87} (12), 1214--1225.
  https://doi.org/10.1016/j.mayocp.2012.08.013
\item
  Mehr, S. E., Barbul, A., \& Shibao, C. A. (2018). Gastrointestinal
  symptoms in postural tachycardia syndrome: A systematic review.
  \emph{Clinical Autonomic Research}, \emph{28}(4), 411--421.
  https://doi.org/10.1007/s10286-018-0519-x
\item
  Loavenbruck, A., Iturrino, J., Singer, W., Sletten, D. M., Low, P. A.,
  Zinsmeister, A. R., \& Bharucha, A. E. (2015). Disturbances of
  Gastrointestinal Transit and Autonomic Functions in Postural
  Orthostatic Tachycardia Syndrome. \emph{Neurogastroenterology and
  Motility : The Official Journal of the European Gastrointestinal
  Motility Society},\emph{27}(1), 92--98.
  https://doi.org/10.1111/nmo.12480
\end{enumerate}

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