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How Should Dizziness, Low Grade Fever, Nausea And Vomiting For Over 2 Weeks Be Treated?
Question: Goddaughter is having symptoms of dizziness x 2 weeks, with recent onset of low grade fever, nausea and vomiting, and bilateral upper extremity weakness. Went to urgent care, and labs (including thyroid function studies) were normal. Referred to a neurologist, who suggested that she was perhaps having migraines, or POTS symptoms (HR went from 93 to 126 with change from sitting to standing position). No history of recent exposure to mosquitoes or ticks, and no recent head trauma. Has appointment with her primary care MD tomorrow; any other pertinent questions we should be asking?
Brief Answer:
POTS is a reasonable diagnosis from neurological perspective
Detailed Answer:
Thank you for your question.
I believe that your description of symptoms and work up to this point is quite adequate and pertinent to your goddaughter's case.
With a heart rate of 93-126 upon postural change and assuming that she is not significantly dehydrated or taking any type of medication or drug that could cause this type of cardiac response....then, the diagnosis of POTS is almost certainly going to be responsible for many of her symptoms and complaints.
The low grade fever may be indicative of a viral syndrome or another infection brewing. I'm not sure about the bilateral upper extremity weakness since weakness is more typically related as being generalized. It could be that weakness in the legs may not be as noticeable. I would appeal to the neurologist's actual examination results to tell whether or not there is actual clinical weakness.
However, if in fact there were FOCAL (though bilateral) UPPER EXTREMITY and NOT lower extremity weakness then, I might be slightly concerned for some type of spinal cord problem and then, I'd look for something such as a syrinx...less likely something in the brain.....however, if I did find her to be focally weak north of the waist only then, I'd order a cervical spine MRI and MRA of the head and neck looking for either a syrinx of the c-spine or a possible vascular anomaly or even dissection that could explain this weakness. I'd also ask whether or not the weakness in the upper extremities depended upon position/posture or relates to the tachycardia?
Migraine as an etiology to symptoms of nausea and vomiting and as a reflection of the POTS is altogether possible but migraine headaches often accompany the diagnosis of POTS in the company of other things such as IBS, and other signs of autonomic dysfunction which could be Orthostatic HYPOTENSION or something else.
Good thought to rule out some form of tick borne disease....I would definitely do Lyme titers and even blood cultures for other types of infectious diseases. But in my opinion the money to the cure on finding the cause of the POTS and/or Orthostatic hypotension (if present) and then, treating that...or if unable to find the cause after full workup (including imaging of the head and neck) to use appropriate medications to treat the POTS.
I would also make sure she had a full AUTONOMIC SYSTEM WORKUP. There are only a few places in the U.S. where I believe such complete workups can be done by qualified specialists so be careful of going to anyone who claims to know about doing autonomic workups just because they have or have access to a tilt table....that is only one component of an autonomic workup.
P.S. Don't forget to have her checked for illicit substances in both blood and urine...I can't tell you how many times we've found such things present in young adults with crazy symptoms coming out of the blue but because the ER was focused on not "hurting any one's feelings" and wanting to be "delicate" with concerned parents...etc.....that they just assumed nothing could be present. ALL YOUNG ADULTS...and by young I mean <50 years old.....and maybe I should XXXXXXX that number to <80 since all the 65-75 year olds of the world were Flower Children who themselves were the biggest experimenters with the biggest variety of illicit substances known to man!
POTS is a reasonable diagnosis from neurological perspective
Detailed Answer:
Thank you for your question.
I believe that your description of symptoms and work up to this point is quite adequate and pertinent to your goddaughter's case.
With a heart rate of 93-126 upon postural change and assuming that she is not significantly dehydrated or taking any type of medication or drug that could cause this type of cardiac response....then, the diagnosis of POTS is almost certainly going to be responsible for many of her symptoms and complaints.
The low grade fever may be indicative of a viral syndrome or another infection brewing. I'm not sure about the bilateral upper extremity weakness since weakness is more typically related as being generalized. It could be that weakness in the legs may not be as noticeable. I would appeal to the neurologist's actual examination results to tell whether or not there is actual clinical weakness.
However, if in fact there were FOCAL (though bilateral) UPPER EXTREMITY and NOT lower extremity weakness then, I might be slightly concerned for some type of spinal cord problem and then, I'd look for something such as a syrinx...less likely something in the brain.....however, if I did find her to be focally weak north of the waist only then, I'd order a cervical spine MRI and MRA of the head and neck looking for either a syrinx of the c-spine or a possible vascular anomaly or even dissection that could explain this weakness. I'd also ask whether or not the weakness in the upper extremities depended upon position/posture or relates to the tachycardia?
Migraine as an etiology to symptoms of nausea and vomiting and as a reflection of the POTS is altogether possible but migraine headaches often accompany the diagnosis of POTS in the company of other things such as IBS, and other signs of autonomic dysfunction which could be Orthostatic HYPOTENSION or something else.
Good thought to rule out some form of tick borne disease....I would definitely do Lyme titers and even blood cultures for other types of infectious diseases. But in my opinion the money to the cure on finding the cause of the POTS and/or Orthostatic hypotension (if present) and then, treating that...or if unable to find the cause after full workup (including imaging of the head and neck) to use appropriate medications to treat the POTS.
I would also make sure she had a full AUTONOMIC SYSTEM WORKUP. There are only a few places in the U.S. where I believe such complete workups can be done by qualified specialists so be careful of going to anyone who claims to know about doing autonomic workups just because they have or have access to a tilt table....that is only one component of an autonomic workup.
P.S. Don't forget to have her checked for illicit substances in both blood and urine...I can't tell you how many times we've found such things present in young adults with crazy symptoms coming out of the blue but because the ER was focused on not "hurting any one's feelings" and wanting to be "delicate" with concerned parents...etc.....that they just assumed nothing could be present. ALL YOUNG ADULTS...and by young I mean <50 years old.....and maybe I should XXXXXXX that number to <80 since all the 65-75 year olds of the world were Flower Children who themselves were the biggest experimenters with the biggest variety of illicit substances known to man!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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