Case Study: Persistent Positional Vertigo Following COVID-19 Infection in a Patient with Multiple Comorbidities

Case at a Glance

A 61-year-old female with a complex medical history including type 1 diabetes, Hashimoto's thyroiditis, MCAS, and HaTS presented with a one-year history of severe, episodic positional vertigo. The symptoms began after a SARS-CoV-2 infection. Initial workup, including neuroimaging, was unremarkable, and a common diagnosis of BPPV was dismissed by the initial specialist due to the chronicity of the symptoms.

Patient's Story

The patient is a 61-year-old female with a known history of type 1 diabetes, Hashimoto's thyroiditis, Mast Cell Activation Syndrome (MCAS), and Hereditary alpha-tryptasemia syndrome (HaTS). For over a year, she has experienced debilitating episodes of severe vertigo, dizziness, and loss of balance, occasionally accompanied by mild nausea. These symptoms commenced shortly after her fourth documented SARS-CoV-2 infection. She recalls a similar, but self-resolving, episode of dizziness that lasted several weeks after her first COVID-19 infection in 2020. The current episodes are specifically triggered by positional changes, such as leaning back, lying down, or standing up, with symptoms being most severe when reclining. The spinning sensation is intense but brief, lasting only a few seconds per episode.

Initial Assessment

The patient sought evaluation from an Otolaryngologist (ENT). Examination of the ears and sinuses was unremarkable. A nasopharyngoscopy was performed, which reportedly revealed an unspecified 'lesion' in the throat. Given the persistent nature of the vertigo, the ENT suspected a central neurological cause, primarily Multiple Sclerosis (MS).

The Diagnostic Journey

To investigate for a central etiology, a non-contrast MRI of the head and a CT scan of the throat were performed. Both imaging studies were normal, providing no evidence of demyelination, stroke, or structural abnormalities. The patient proposed the possibility of Benign Paroxysmal Positional Vertigo (BPPV), but the physician dismissed this diagnosis, stating that the condition's duration of over a year was too long for BPPV. Postural Orthostatic Tachycardia Syndrome (POTS) was also briefly considered but ruled out, as the patient reported a history of high blood pressure, not orthostatic intolerance. The inconclusive results and dismissal of a likely peripheral cause left the patient without a diagnosis or treatment plan, leading to the consideration of seeking a second opinion from a different specialist or her general practitioner.

Final Diagnosis

Presumptive Diagnosis: Persistent/Recurrent Benign Paroxysmal Positional Vertigo (BPPV), likely as a post-viral complication. The patient's clinical presentation—brief, intense, rotational vertigo triggered by specific changes in head position—is pathognomonic for BPPV. Chronicity does not rule out BPPV, as it can be persistent or have frequent recurrences if left untreated.

Treatment Plan

The recommended course of action begins with a diagnostic Dix-Hallpike test to confirm BPPV and identify the affected semicircular canal. Upon confirmation, the primary treatment is a non-invasive Canalith Repositioning Procedure (CRP), such as the Epley maneuver, which can be performed in-office. For any residual dizziness or imbalance following successful CRP, referral for vestibular rehabilitation therapy would be beneficial.

Outcome and Follow-up

The patient was advised to seek a second opinion from her primary care physician or a specialist in vestibular disorders (neuro-otologist or another ENT) for definitive diagnostic testing. With an accurate diagnosis and appropriate CRP treatment, the prognosis for resolution of vertigo is excellent. Follow-up would involve monitoring for symptom recurrence, which can occur with BPPV, and continued management of her multiple chronic conditions, which are integral to her overall health and recovery.