Lyme Disease and POTS: Can POTS Start After Lyme?

Quick answer

POTS (postural orthostatic tachycardia syndrome) is a condition in which your heart rate jumps when you stand, often with dizziness, fatigue and brain fog. It often starts after a viral illness or other stressor. Published case reports describe POTS developing after Lyme disease, but a direct cause has not been established. A tilt table or standing test is used to diagnose it.

What POTS is

POTS is one of a group of conditions involving orthostatic intolerance, which means symptoms that come on when you are upright and get better when you lie down. NINDS says the classic symptom is a fast heartbeat. Other common symptoms include:

• Dizziness or lightheadedness, and sometimes fainting
• Palpitations, especially on standing
• Exhaustion and trouble concentrating
• Headaches, blurred or tunnel vision, and leg weakness
• Sleep problems, digestive issues and shortness of breath

NINDS says POTS mostly affects people ages 15 to 50 and is more common in women. Cleveland Clinic estimates it affects more than 500,000 people in the U.S. NINDS also lists conditions that often occur with it, including ME/CFS, long COVID, migraine and hypermobile Ehlers-Danlos syndrome.

Infections as reported triggers

Both NINDS and Cleveland Clinic note that POTS often begins after a stressor. Cleveland Clinic names viral illnesses such as mononucleosis and COVID-19, along with pregnancy, head injury and surgery. NINDS says researchers are studying the link with COVID-19 and a possible autoimmune component in some people. A 2022 Nature Medicine review of post-infection syndromes (Choutka and colleagues) also listed dysautonomia, the family of nerve-system problems that includes POTS, among their typical features.

Neither NINDS nor Cleveland Clinic lists Lyme disease specifically as a trigger.

What is known about POTS after Lyme

The published evidence linking POTS and Lyme disease that we found comes from case reports, which describe individual patients rather than test cause and effect. For example, a 2011 report in Cardiology Journal (Kanjwal, Grubb and colleagues) described five women, ages 22 to 44, who had been treated for Lyme disease and later developed fatigue, brain fog, palpitations on standing and near-fainting. POTS was diagnosed with tilt table testing. The authors reported that all five responded to POTS treatment and four returned to work or school, and suggested that doctors consider POTS in post-Lyme patients with these symptoms.

What case reports like this can and cannot tell us:

• They show that POTS can occur in people who have had Lyme disease and that it can be recognized and treated.
• They cannot show that Lyme caused the POTS, how often it happens, or whether it happens more than after other infections. The 2011 report had five patients and no comparison group.

If your fast heartbeat started after a tick bite, tell your clinician so they can consider active Lyme disease, which is treated with antibiotics, as well as POTS. Our guides to Lyme testing and post-treatment Lyme disease syndrome explain the next steps.

How POTS is diagnosed

NINDS says POTS can be hard to diagnose because its symptoms resemble other conditions, which often delays diagnosis. Testing usually includes:

• A standing test. Your clinician checks your heart rate and blood pressure lying down and again after you stand.
• A tilt table test. You lie on a table that tilts you upright while heart rate and blood pressure are monitored. A large rise in heart rate without a major drop in blood pressure strongly suggests POTS, per NINDS.
• Other tests to rule out other causes, such as blood and urine tests. Cleveland Clinic also describes sweat and breathing tests of the autonomic nervous system in some cases.

A tip: before your visit, keep a short log of symptoms when standing, along with any tick bites or recent illnesses. Our guide to preparing for your doctor visit can help.

Who to see and treatment

NINDS notes that people with POTS are often referred to a cardiologist or neurologist. Cleveland Clinic recommends a care team experienced with POTS. Start with your primary care clinician, who can do an initial standing check and refer you.

There is no cure, and the FDA has not approved a medicine specifically for POTS, according to Cleveland Clinic. Treatment focuses on easing symptoms and may include:

• More fluids and salt, if your clinician agrees this is safe for you
• Waist-high compression garments
• A gradual, often reclined, exercise program, though NINDS notes this is not right for everyone, especially people with exercise intolerance
• Medicines your clinician may consider for short-term relief

NINDS advises talking with a clinician before starting or stopping any medicine, because some medicines can cause or worsen POTS symptoms. If you also crash after exertion, ask about ME/CFS; see Lyme and ME/CFS. For more on living with ongoing symptoms, see Step 6 of How to beat Lyme.

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