Differentiating POTS from Other Conditions

CHICAGO—To provide some clarity to a condition that remains largely misunderstood and clinically controversial, experts at an ACR Convergence 2025 session focused on postural tachycardia syndrome (POTS), a condition that is thought to affect as many as 3 million people in the U.S.

In the session POTS: Postural Tachycardia Syndrome or Is It?, the speakers were Brittany Adler, MD, assistant professor of medicine at Johns Hopkins University, Baltimore, and Albert “Fin” Mears Jr, PT, physical therapist at Johns Hopkins University, who both work with a multidisciplinary team in the POTS Center.

As a condition that involves sympathetic vasomotor dysfunction, common symptoms of POTS include fatigue, brain fog, headache, orthostatic intolerance, muscle pain and difficulty exercising.1 Its diverse potential etiologies and mechanisms are similar to immune-mediated processes including COVID-19, Lyme disease and Epstein-Barr virus, as well as several autoimmune conditions, such as Sjogren’s disease, systemic lupus erythematosus and celiac disease. Given the potential connections to autoimmune disorders, rheumatologists need to become familiar with the symptoms associated with POTS to help differentiate it from a potential autoimmune condition.

It’s POTS … Or Is It?

Dr. Adler

Dr. Adler discussed how to differentiate POTS from other syndromes with similar clinical features that overlap with other dysautonomia syndromes. She highlighted cases of POTS and dysautonomia that rheumatologists might encounter in their everyday practice and discussed how physicians can distinguish key symptoms of POTS from such overlapping conditions as myalgic encephalomyelitis/chronic fatigue syndrome, mast cell activation and other autonomic disorders.

She said that POTS and other forms of dysautonomia are already in rheumatology practices but that they are not yet recognized by rheumatologists. “Rheumatologists should include dysautonomia in the differential diagnosis when evaluating patients with systemic symptoms and develop a working knowledge of these conditions,” she said, adding that recognizing POTS can lead to better management of a subset of patients whose symptoms don’t fit neatly into a traditional rheumatic diagnosis.

Dr. Adler cautioned, however, that diagnosing patients with POTS is complicated and tricky, and the syndrome can be diagnosed only by clinical presentation because of the lack of a lab biomarker. She used several case studies to illustrate what rheumatologists should look for when making the differential diagnosis of POTS, and ended her talk by highlighting the red flags that rheumatologists should be looking for. Among the most prominent symptoms of POTS, she said, is nonspecific fatigue and brain fog. Other symptoms include orthostatic intolerance, gastrointestinal symptoms, recurrent interstitial cystitis, hypermobility/Ehlers-Danlos syndrome, concurrent pain syndrome or small-fiber neuropathy, color changes in dependent extremities and flushing and itching hives.