key: cord-0071647-inm1uma7
authors: Karimi Galougahi, Keyvan
title: Autonomic dysfunction post-inoculation with ChAdOx1 nCoV-19 vaccine
date: 2021-11-27
journal: Eur Heart J Case Rep
DOI: 10.1093/ehjcr/ytab472
sha: fc6ec62546e85dee4ae8c515261722d9164a78d8
doc_id: 71647
cord_uid: inm1uma7

nan

Autonomic dysfunction in a healthy 29-year-old male after a single dose of the ChAdOx1 nCoV-19 vaccine (AstraZeneca). (A) A significant increase in the average daily heart rate was noted on a smart watch (Apple Inc.), starting around 2 months after inoculation with the first dose of the vaccine, which was associated with palpitations. With lifestyle modifications, palpitations and the increase in heart rate settled after 3 months. (B) Intermittent mottling in the hands and (C) blood pooling and dependent acrocyanosis with very sluggish capillary refill in the feet were exacerbated by orthostatic position for prolonged periods of time. skin colour changes (dark-blue/white/dark-red) in acral areas (hands/ feet/penis), with mottling and blood pooling/dependent acrocyanosis with sluggish capillary refill ( Figure 1B and C) . He had intermittent palpitations, dizziness, and worsening of paraesthesia and skin colour changes especially with prolonged standing, exertion, food intake, or changes in the temperature in the environment, with no pre-syncope or syncope. He also developed difficulty achieving and maintaining an erection.

On examination, recumbent blood pressure/heart rate of 130/ 70 mmHg/75 b.p.m. changed to 130/70 mmHg/98 b.p.m., 120/ 80 mmHg/100 b.p.m., and 120/85 mmHg/106 b.p.m. on 1, 3, and 5 min of standing. Electrocardiogram and echocardiography were normal, with rare atrial ectopic beats on 24-h Holter monitor. On autoimmune serology, only antinuclear antibody (ANA) was positive at low titre (speckled pattern, 1:40) with elevated IgA level [5.06 g/L (0.60-3.96)], which did not fulfil the diagnostic criteria for an autoimmune disorder. Limbic encephalitis antibody panel, glutamic acid decarboxylase antibodies, anti-neuronal antibody, and anti-ganglionic acetylcholine receptor antibody were negative. Magnetic resonance imaging of brain-spine and nerve conduction study were normal. With a diagnosis of autonomic dysfunction/postural orthostatic tachycardia syndrome, he received an empiric 5week course of steroid, with no change in symptoms. With lifestyle modifications, postural tachycardia improved, but paraesthesia and skin colour changes persisted at 6-months.

Autonomic dysfunction can occur secondary to viruses, including post-COVID-19, 1 and vaccines, with a single case reported after the Comirnaty BNT162b2 mRNA vaccine for COVID-19 (Pfizer-BioNTech), 2 although no cases have been reported with the ChAdOx1 nCoV-19 vaccine. Aetiology is unknown but may be mediated via autoimmunity against autonomic ganglia, fibres, or receptors 3 ; or other receptors (e.g. ACE 4 ). Further studies are needed to determine the prevalence, aetiology, and management of autonomic dysfunction secondary to COVID-19 vaccination.

Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients

A case of postural orthostatic tachycardia syndrome secondary to the messenger RNA COVID-19 vaccine

Autoimmune basis for postural tachycardia syndrome

Abnormalities of angiotensin regulation in postural tachycardia syndrome

The author thanks Drs Razieh Soltani-Arabshahi, Seyed Shahin Sharifi, Reza Vaez-Afshar, Elham Jafarimojarrad, and Ahmad Sajjadi for useful discussions of the case.

The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.Conflict of interest: None declared. Funding: None declared.