BMJ Case Reports 2018; doi:10.1136/bcr-2017-221405
  • Novel treatment (new drug/intervention; established drug/procedure in new situation)

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

Open Access
  1. Brent Goodman5
  1. 1Medicine, Washington University, Saint Louis, Missouri, USA
  2. 2Gastroenterology, Specialists in Gastroenterology, Saint Louis, MO, USA
  3. 3Biostatistics, Private Practice, Anchorage, Alaska, USA
  4. 4Gastrointestinal Department, Specialists in Gastroenterology, Saint Louis, Missouri, USA
  5. 5Department of Neurology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
  1. Correspondence to Dr Leonard B Weinstock, lw{at}
  • Accepted 22 December 2017
  • Published 11 January 2018


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.


  • Contributors LBW: treating physician diagnosed and treated POTS, MCAS and SIBO; wrote majority of manuscript. JBB: tabulated table 1 and contributed to case report writing, references and critically reviewed manuscript. TLM: acquired and contributed to references, wrote part of introduction and critically reviewed manuscript. BG: treating physician diagnosed and treated POTS and MCAS, wrote part of discussion and critically reviewed manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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