Successful treatment of postural orthostatic tachycardia and mast cell activation syndromes using naltrexone, immunoglobulin and antibiotic treatment

BMJ Case Rep. 2018 Jan 11;2018:bcr2017221405. doi: 10.1136/bcr-2017-221405.


A patient with severe postural orthostatic tachycardia syndrome (POTS) and mast cell activation syndrome (MCAS) received immunotherapy with low-dose naltrexone (LDN) and intravenous immunoglobulin (IVIg) and antibiotic therapy for small intestinal bacterial overgrowth (SIBO). A dramatic and sustained response was documented. The utility of IVIg in autoimmune neuromuscular diseases has been published, but clinical experience with POTS is relatively unknown and has not been reported in MCAS. As a short-acting mu-opioid antagonist, LDN paradoxically increases endorphins which then bind to regulatory T cells which regulate T-lymphocyte and B-lymphocyte production and this reduces cytokine and antibody production. IVIg is emerging as a promising therapy for POTS. Diagnosis and treatment of SIBO in POTS is a new concept and appears to play an important role.

Keywords: clinical neurophysiology; drugs: gastrointestinal system; immunological products and vaccines; immunology; therapeutic indications.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Anti-Bacterial Agents / administration & dosage*
  • Blind Loop Syndrome / drug therapy*
  • Drug Therapy, Combination
  • Female
  • Humans
  • Immunoglobulins, Intravenous / administration & dosage*
  • Intestine, Small / microbiology
  • Mastocytosis / drug therapy*
  • Naltrexone / administration & dosage*
  • Narcotic Antagonists / administration & dosage*
  • Postural Orthostatic Tachycardia Syndrome / drug therapy*


  • Anti-Bacterial Agents
  • Immunoglobulins, Intravenous
  • Narcotic Antagonists
  • Naltrexone