Orthostatic Intolerance (OI) refers to a heterogeneous group of disorders of hemodynamic regulation characterized by insufficient cerebral perfusion resulting in symptoms during upright posture relieved by recumbency. To our knowledge this would be the first case to describe a patient with type 1 diabetes mellitus (T1DM) who underwent bariatric surgery and developed debilitating OI. We describe the case of a 46 year old with class III obesity (BMI 42.9), T1DM, complicated by microalbuminuria, diabetic retinopathy, carpal tunnel syndrome, and HTN status post gastric sleeve surgery who presented to the emergency department 10 days after surgery for a syncopal episode, which resulted in head trauma. He endorsed multiple episodes of lightheadedness and falling after surgery. He lost 20 lbs in the first 10 days. His systolic blood pressure was 70 mmHg, however no other physical exam, laboratory, or imaging abnormalities were found. Thereafter he continued to have similar episodes and was only found to have a positive Tilt Test after extensive outpatient workup. He was started on midodrine 5 mg three times a day, fludrocortisone acetate 0.1 mg daily, and Pyridostigmine 60 mg three times a day with resolution of symptoms. There is a relationship between obesity and hypertension, possibly associated to its effect on the renin angiotensin aldosterone system, up regulation of sympathetic nervous system and simultaneous down regulation of parasympathetic nervous system. Bariatric surgery increases the risk of developing OI through the effects of weight loss itself, the type of procedure chosen and ultimately, vitamin deficiencies. Patients with diabetes are also at risk of developing OI following these procedures due to underlying Diabetic Autonomic Neuropathy (DAN) that had been masked by obesity related HTN. Physicians should be mindful of the risk of OI after bariatric surgery, especially in patients with possible underlying DAN. Close follow up is advised for these patients to avoid falls and trauma.


Z. Cardona: None. Y. Haider: None.

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