"Panic From Covid-19" - Autonomic Dysfunction In An Elite Tennis Player.

HISTORY: An 19 year old elite tennis player presented to the sports medicine clinic with complaints of persistent fatigue and underperformance following a SARS-COVID-19 (PCR+) infection. The athlete lives at a high performance academy and is home schooled at the academy. She tested positive at end of July (mostly systemic viral symptoms without dyspnoea) and followed the well accepted "return to sport programme" but now 3 months later still complains of inability to progress with her return to sport based on an extremely rapid rise in heart rate and episodes of fatigue. She also co persistent sore throat & anosmia. Previous medical history -non contributary except for previous sleep disorder and low ferritin at times. MEDICATIONS: Methylfenidate 10 mg daily, (increased to 36 mg daily) Oral iron supplement, melatonin, Vit C & D supplement. Physical examination revealed normal general, cardiovascular, neurological and respiratory systems. BP 130/70, Pulse rate 50 regular. Blood lab values for CBC, Ferritin, Vit D, U&E, D-dimer and CRP all WNR. SPECIAL INVESTIGATIONS: Resting ECG - Normal sinus rhythm 41 bpm - no conduction or other abn.Echo - Normal study - no TR or PR despite provocationStress Echo - appropriate increase in systolic function and increasing diastolic function during exercise. RV function response to exercise normal, Direct laryngoscopy-normal. Patient was discharged with reassurance that fatigue will abate over time and to continue to have mild exercise under the guidance of an athletic trainer. She is to monitor her fatigue-like symptoms. Three months later, she returned to the clinic complaining of "panic attacks" and requested referral to a psychologist. She describes the attacks as "impending death" rapid heart rate and sweatiness. On examination, all systems normal. BP 126/76 mmHg pulse rate 56 bpm. However on standing up suddenly after the examination, she appeared pale and claimed to be having a panic attack. Pulse rate on standing 133 bpm and BP 90/70 mmHg. She immediately recovered after 30 sec of placement in supine position with legs raised. DIAGNOSIS: Autonomic dysfunction possibly COVID induced. However, symptoms resolved over the next month and also coincided with withdrawal of methylfenidate. She is well at present 6 months later, and has returned to tennis training without symptoms.