Case report: improving POTS and chronic fatigue symptoms—and what changed after COVID

Educational medical disclaimer: This article summarizes a single clinical case discussion from Dr. Patrick Nemechek’s video and reflects his clinical interpretation and framework. It is not medical advice, does not diagnose or treat any condition, and should not replace individualized care from your clinician.

In this video case report, Dr. Patrick Nemechek describes a young woman who developed a sudden onset of symptoms that led to a diagnosis of postural orthostatic tachycardia syndrome (POTS). In retrospect, he notes she likely also fit a chronic fatigue syndrome/myalgic encephalomyelitis (ME/CFS) picture, particularly given her post-exertional fatigue and the way her symptoms shifted over time.

He walks through her symptom pattern, the sequence of interventions he used in his protocol, and how her progress changed after an acute COVID infection. The goal of the case report is to illustrate how he thinks about symptom clusters, why he may layer multiple strategies when testing is limited, and how he approaches a setback when a patient had been improving.

Initial presentation: sudden fatigue, brain fog, nausea, and headaches

Dr. Nemechek describes the patient as previously healthy through high school and college with no major baseline issues. She was working as an accountant and CPA when she developed a sudden onset of:

• Fatigue
• Brain fog
• Nausea
• Headaches

After seeing multiple clinicians, she was diagnosed with POTS. Looking back, Dr. Nemechek explains that this kind of sudden onset can also align with ME/CFS, which he says is often triggered by what may seem like a mild viral illness—sometimes an illness people don’t even remember clearly.

He also describes additional features that complicated her day-to-day functioning:

• Gastroparesis-related nausea, which he frames as a neurological issue affecting stomach emptying
• Temperature regulation problems, including heat intolerance severe enough that she kept her bedroom near 60°F to feel comfortable

Dr. Nemechek’s framework: symptoms improving when lying flat

One clinical detail he highlights is that her symptoms improved significantly when she laid flat. In his interpretation, this pattern suggests difficulty generating appropriate blood pressure in the brain. He explains that when gravity is reduced by lying flat, symptoms can ease—potentially because oxygen diffusion to neurons may improve when cerebral perfusion pressure is less challenged.

At the same time, he notes the obvious limitation: a person cannot live a normal life lying flat, so the aim is functional improvement while upright.

Starting the protocol: VNS, fish oil, olive oil, and continuous rifaximin

Dr. Nemechek says he started her on his “basic protocol,” which in this case included:

• VNS for two hours a day
• Fish oil
• Olive oil

Because of symptom severity, he chose to use continuous rifaximin (he pronounces it “refax/min” in the recording), initially anticipating roughly four to six months before transitioning to an intermittent approach.

Over the next couple of months, he reports meaningful improvement: headaches that had been nearly daily decreased to only a couple days per week. She also perceived that cognition/brain fog and fatigue were improving—especially on days when headaches were absent.

Progress over months: brain fog improving, fatigue improving, but post-exertional symptoms persist

As the case continued into roughly the five- to six-month range, Dr. Nemechek describes her brain fog as “substantially better,” and fatigue starting to improve enough that she would occasionally have a “good day.” However, she still experienced post-exertional fatigue, which he notes is common in ME/CFS. He describes the familiar pattern many patients report: doing more on a good day and then “paying for it” the next day.

He also emphasizes that, in his words, the reason for post-exertional fatigue isn’t exactly known, but the pattern is typical in ME/CFS.

A setback after COVID: “gets whacked by Co”

After this period of improvement, she contracted COVID, and Dr. Nemechek reports she worsened. In the weeks following infection, he observed that rifaximin did not seem to be working as well as before. He notes that long-term drug resistance to rifaximin is not known to exist in the way people might assume, so he considered other explanations within his framework.

His first adjustment was to add inulin, which he describes as his preferred prebiotic. In this case, he used inulin at “a quarter teaspoon twice a day,” and it appeared to help somewhat, though things still felt “off.”

Adding glutamine in his post-COVID “leaky gut” framework

Dr. Nemechek then connects the ongoing post-COVID difficulties to an idea he mentions in other videos: that COVID can cause a different form of “leaky gut.” In his clinical interpretation, this may be related to COVID triggering a deficiency state involving the amino acid glutamine.

Because of that, he added powdered glutamine (“a level tablespoon twice a day,” as stated in the recording). He describes this addition as a turning point: she “dramatically improves” over the next few months, reporting that most days she felt normal. He also notes she was no longer experiencing post-exertional fatigue the following day even when she pushed herself.

Functionally, she began testing her capacity by returning to part-time accounting work.

Stepping down: stopping glutamine and moving to intermittent rifaximin/inulin

Dr. Nemechek explains that the first step-down was stopping glutamine, and she did well without signs of relapse. He describes glutamine deficiency in this context as typically short-lived and says that if glutamine helps, he generally keeps people on it for about three to four months, after which internal production tends to be sufficient.

At the time of the recording, he reports she was on an intermittent approach with rifaximin and inulin. If certain intestinal symptoms and anxiety “spike up,” her plan was to take both inulin and rifaximin twice a day for 10 days as a way to stop the flare.

He notes she stayed on fish oil and olive oil, and that she chose to continue VNS because she felt it helped her cognition.

Clinical takeaway Dr. Nemechek highlights: adapting when testing can’t narrow the cause

Dr. Nemechek closes by describing this as a “very typical case” in his practice experience—one where a patient may need continuous rifaximin when very sick, and where an interruptive process such as COVID may require combining strategies (for example, adding inulin, and then adding glutamine when he suspects a COVID-related secondary gut issue).

He also underscores a practical limitation: he would prefer to test and precisely identify what is happening, but he states that the testing to narrow it down is not available. In that setting, he describes sometimes treating “a couple things at one time,” monitoring for improvement, and then “working your way out of the problem” step by step.

Finally, he states his view directly: “POTS is reversible.” (This is his statement from the video and reflects his position within this case discussion.)