COVID-19 Can Cause Platypnoea-Orthodeoxia Syndrome and Case Reports of Individuals Developing it are Increasing

Medical News: Platypnoea-orthodeoxia syndrome (POS) is a rare medical condition where individuals experience difficulty breathing (dyspnea) and low oxygen levels (hypoxia) when in an upright or sitting position. The condition improves when the affected person lies down. POS is typically linked to heart diseases, such as a patent foramen ovale (PFO), which allows blood to bypass normal circulation and mix oxygenated and deoxygenated blood. However, lung diseases or infections and other factors can also contribute to the development of this syndrome.


COVID-19 Can Cause Platypnoea-Orthodeoxia Syndrome and Case Reports of Individuals Developing
it are Increasing

POS has been associated with various conditions, including pulmonary diseases, interstitial lung disease, and liver disease. However, its occurrence in COVID-19 patients has recently drawn attention. Cases of POS related to COVID-19 pneumonia are increasing, but the condition often goes unnoticed due to its unusual presentation. This Medical News explores the link between COVID-19 and POS, the challenges in diagnosis, and the possible mechanisms behind this complication.
 
POS and Its Link to COVID-19
COVID-19 affects the lungs in various ways, with some patients developing severe pneumonia and complications such as acute respiratory distress syndrome (ARDS). While POS is not a commonly recognized outcome of COVID-19, case reports indicate that it might be more prevalent than previously thought. The primary mechanism suspected in COVID-19 patients is related to changes in lung blood flow and ventilation-perfusion mismatch - where oxygen delivery does not match the blood flow within the lungs.
 
A key characteristic of COVID-19 is the presence of ‘happy hypoxemia,’ a condition where patients exhibit extremely low oxygen levels without experiencing significant respiratory distress. This can make it difficult to detect POS, as patients may not initially appear to struggle with breathing. However, when oxygen levels are monitored in different positions, POS can be identified. As the patient sits upright, oxygen saturation drops significantly, only to improve when they lie down again.
 
How POS Develops in COVID-19 Patients
POS in COVID-19 patients is believed to arise due to several factors. The most common explanation is that the disease causes structural damage to the lungs, particularly in the lower lobes, leading to abnormal blood flow distribution. The inflammation and fibrosis (scarring) caused by COVID-19 pneumonia affect how oxygen is absorbed into the bloodstream. Gravity also plays a role - when an individual stands up, blood moves to the lower parts of the lungs, but in cases where these areas are damaged, oxygen exchange is impaired.
 
Another proposed mechanism is related to microvascular damage and clotting abnormalities seen in COVID-19 patients. Microthrombi, or tiny blood clots, can block oxygen exchange, worsening POS symptoms. The presence of these small clots can contribute to oxygen desaturation when standing up. Additionally, COVID-19 can affect the heart, leading to dysfunction that exacerba tes POS symptoms. Studies have suggested that myocardial dysfunction, or heart muscle weakness, could further decrease blood flow in certain lung regions, worsening the condition.
 
Diagnosis and Challenges in Identifying POS
Diagnosing POS requires careful observation and specific testing, as it is often overlooked in standard clinical assessments. Most oxygen saturation measurements are taken while a patient is lying down, which can mask the presence of POS. To accurately diagnose this condition, oxygen levels should be measured in both supine and upright positions. A drop in oxygen levels of more than 5% when standing suggests POS.
 
Doctors also use imaging techniques, such as contrast-enhanced CT scans and echocardiography, to identify potential shunts or structural abnormalities in the heart and lungs. In COVID-19 patients, CT scans often reveal fibrotic changes in the lungs, which can contribute to the development of POS. Blood tests measuring markers of clotting abnormalities, such as D-dimer levels, may also provide clues about the underlying causes of POS in these patients.
 
Treatment and Management
Managing POS in COVID-19 patients requires a combination of oxygen therapy and targeted treatments to address the underlying cause. In cases where a cardiac shunt is responsible for POS, closure of the shunt may be necessary. However, in COVID-19-related POS, treatment focuses on improving lung function and reducing inflammation. Oxygen supplementation is often used to maintain adequate oxygen levels. In some cases, respiratory therapy and positioning techniques, such as encouraging patients to remain in positions that maximize oxygenation, can help manage symptoms.
 
Additionally, anticoagulant therapy may be prescribed to address clotting abnormalities seen in COVID-19 patients. As researchers continue to study POS, new therapeutic strategies may emerge, particularly for patients who experience persistent lung damage after recovering from COVID-19.
 
Example of some case reports of COVID-19 causing Platypnoea-orthodeoxia syndrome
https://publications.ersnet.org/content/erj/58/suppl65/pa3895
 
https://www.ijccm.org/abstractArticleContentBrowse/IJCCM/27241/JPJ/fullText
 
https://ejb.springeropen.com/articles/10.1186/s43168-022-00124-y
 
https://www.ejcrim.com/index.php/EJCRIM/article/download/2849/2860?inline=1
 
https://casereports.bmj.com/content/14/5/e243016
 
https://www.mattioli1885journals.com/index.php/actabiomedica/article/view/12824
 
https://www.sciencedirect.com/science/article/abs/pii/S2212534524000169
 
https://journals.lww.com/annals-of-medicine-and-surgery/fulltext/2023/11000/association_between_covid_19_infection_and.89.aspx
 
https://de-intensivist.nl/platypnoea-orthodeoxia-syndrome-in-covid-19-patient-leads-to-discovery-of-a-transient-cardiac-condition/
 
https://de-intensivist.nl/platypnoea-orthodeoxia-syndrome-in-covid-19-patient-leads-to-discovery-of-a-transient-cardiac-condition/
 
https://www.medicaljournals.se/jrm/content/html/10.2340/20030711-1000044
 
https://spmfrjournal.org/index.php/spmfr/article/view/472?articlesBySimilarityPage=9
 
https://www.cureus.com/articles/229585-platypnea-orthodeoxia-syndrome-and-covid-19-successfully-treated-with-percutaneous-patent-foramen-ovale-closure-a-report-of-two-cases-and-literature-review#!/
 
https://www.cureus.com/articles/329377-platypnea-orthodeoxia-syndrome-in-relation-to-severe-sars-cov-2-infection#!/
 
https://jaclinicalreports.springeropen.com/articles/10.1186/s40981-021-00471-7
 
https://onlinelibrary.wiley.com/doi/full/10.1002/rcr2.1009
 
https://www.dovepress.com/platypnea-orthodeoxia-syndrome-in-coronavirus-disease-2019-pneumonia-a-peer-reviewed-fulltext-article-IMCRJ
 
Conclusion
While POS has traditionally been considered a rare condition, emerging evidence suggests that it may be more common in COVID-19 patients than previously recognized. The mechanisms behind POS in these patients involve a complex interplay of lung inflammation, fibrosis, ventilation-perfusion mismatch, and microvascular damage. Due to the unique presentation of POS, with symptoms worsening in an upright position and improving when lying down, it is often underdiagnosed in clinical settings. Increased awareness among healthcare professionals is essential to ensure early detection and proper management.
 
Further research is needed to fully understand why some COVID-19 patients develop POS, particularly during the recovery phase. Investigating the long-term effects of lung damage and the role of cardiac dysfunction in these cases will be crucial for improving treatment strategies. In the meantime, careful monitoring of COVID-19 patients for signs of POS and proactive oxygen assessments in different body positions can help identify affected individuals and provide timely intervention.
 
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