📋 Executive Clinical Synthesis
The patient presents with persistent 24/7 non-positional lightheadedness, cognitive lag, and superimposed orthostatic intolerance in the setting of objectively confirmed hyperadrenergic POTS physiology and a documented acute unilateral vestibular asymmetry at symptom onset.
On May 20, 2024, during exertion, the patient experienced an abrupt vestibular event characterized by disequilibrium and visual processing delay. VNG demonstrated a 31°/sec spontaneous nystagmus consistent with acute unilateral vestibular asymmetry. Persistent baseline lightheadedness emerged gradually by fall 2024 and has remained independent of posture since.
Autonomic Profile
Objective autonomic testing demonstrates a hyperadrenergic pattern with tilt heart rate increase >40 bpm without orthostatic hypotension and standing norepinephrine of 630 pg/mL.
❓ Primary Diagnostic Question
Are current symptoms primarily driven by:
- 1 Residual or compensated peripheral vestibular dysfunction
- 2 Central maladaptation (e.g., PPPD) following acute vestibular asymmetry
- 3 Hyperadrenergic POTS physiology contributing to cerebral perfusion instability
- 4 An interaction among vestibular, autonomic, and central integration systems
- 5 Post-viral (e.g., Long COVID) sequelae contributing to multi-system dysregulation
⚙️ Mechanisms Under Review
- • Acute unilateral vestibular asymmetry (31°/sec nystagmus at onset)
- • Reduced total caloric slow component velocity (7°/sec; normal ≥20°/sec)
- • Hyperadrenergic POTS (>40 bpm HR increase; NE 630 pg/mL)
- • Persistent non-positional lightheadedness suggesting central involvement
- • Normal IENFD distal leg/proximal thigh; SGNFD distal leg 38.5% (cutoff ≥38.2%) via Skin Biopsy
- • Multi-system dysregulation post-viral exposure under evaluation
🫀 1. Autonomic & Peripheral Nerve Screen
Norepinephrine (pg/mL)
Tilt Table Data
Pulse pressure narrowed to 12 mmHg at peak tilt (30 Min).
Skin Biopsy (12/4/2025)
👁️ 2. Sensory Hardware Status
Spontaneous Nystagmus
Caloric Results (Sum)
caloric SCV sum 7 deg/sec
Vision Rehab Success
Clinical Observation
Vertical phoria normalized to 0Δ. Jump vergence accuracy at 100%. Total caloric SCV sum documented at 7 deg/sec. Binocular hardware is stabilized; persistent non-positional symptoms suggest evaluation of central integration mechanisms.
🦠 3. Immune, Gut & Vascular Axis
sCD40L
Th2 Shift
GPCRs (U/ml)
Gut Barrier
GPCR Positive Thresholds (U/ml): AT1R/ETAR >17, Alpha-1 >11, Beta-1 >15, Beta-2 >14, Muscarinic M3/M4 >10.7.
🧠 4. Neurologic & Metabolic Axis
ASL Perfusion Analysis
Radiologist Note (ASL MRI)
"The map shows patchy hypoperfusion frontal towards the vertex, deep temporal and occipital lobes bilaterally. Also somewhat diminished activity in the basal ganglia."
No evidence of ischemia, focal infarct, or structural lesions identified.
Mito Interpretation
High Citrate Synthase (306%) indicates a pathological surge in mitochondrial quantity, likely compensating for functional production bottlenecks at Complex I (50%).