Long Covid, MCAS, CFS/ME, POTS, FAQ's in Dallas, TX

Long Covid and related conditions and treatments FAQ's

We do not.  This includes telemedicine consults or in person.  The main reason is that the amount of time that is required to assess, formulate, and treat long covid, MCAS, CFS/ME, and POTS typically exceeds what is allowed by insurance.  Additionally the procedures are performed in an entirely different manner and would not fall under the traditional CPT code.

There isn’t a single test or blood work to tell you have long covid.  Many of the symptoms from long covid overlap with several other conditions, but if your symptoms became worse or started after you had a covid 19 infection or had a covid 19 vaccine or booster, it is most likely from long covid.  Taste and smell abnormalities are somewhat specific to long covid.  More info here.

12 points or
higher and you have long covid according to this one study







Chronic cough


Brain fog




Chest pain






Changes in
sexual desire or capacity










Thaweethai T, Jolley SE,
Karlson EW, et al. 
Development of a definition of postacute sequelae of SARS-CoV-2
JAMA. Published
online May 25, 2023. doi:10.1001/jama.2023.8823.

There are several hypotheses on what causes it. We still don’t know if it is one or more causes. Some believe its direct damage from the covid-19 virus; others believe it’s from the cytokine storm that covid-19 virus creates.   There is some new evidence suggesting chronic inflammation around the olfactory nerve epithelium.  One possible mechanism is the dysautonomia or autonomic nervous system dysfunction that maintains the chronic inflammation.  This one explains most if not all of the symptoms exhibited.  While it goes by many different names: Long Covid or long hauler’s or post-acute covid syndrome (PACS), they all refer to the same constellation of symptoms.

General symptoms
  • Tiredness/exhaustion
  • Post exertional malaise (PEM) – feeling tired after any physical or mental effort
  • Fever
  • Feeling cold or hot, poor temperature control

Cardiovascular/Pulmonary (lung)/respiratory


  • Palpitations/pounding heart
  • High heart rate
  • Shortness of breath
  • Cough
  • Dysphagia (trouble swallowing/painful swallowing)
  • Chest pain
  • Dizziness, lightheadedness
  • Brain fog – difficulty in concentrating and thinking
  • Insomnia/trouble falling asleep or staying asleep
  • Anosmia/hyposmia/parosmia
  • Ageusia/Dysgeusia
  • Vibration sensations throughout body
  • Blurry vision
  • Neuropathies/tingling/pins and needles
  • Tinnitus
  • Vertigo
  • Depression
  • Anxiety
  • PTSD
  • Abdominal pain
  • Diarrhea
  • Abnormal sweat smell like onions or cheese
  • Joint or muscle pains
  • Skin rashes

Certain symptoms appear to occur from a low vagus nerve/parasympathetic tone, while other are more related to the high sympathetic nervous system tone.

Any condition that has damaged or continually damages your nervous system, especially the autonomic nervous system can put you at risk for developing long covid. Diabetes, preexisting POTS, Lyme disease, Rheumatoid arthritis, Lupus (SLE), are just some of the conditions that can put you at risk.  More information is here.

When the sympathetic nervous system (SNS) is kicked into overdrive, it’s out of balance with the parasympathetic and vagus nerve tone. This is most likely due to the initial cytokine storm that can occur during the acute COVID-19 infection.  At the same time the vagus nerve of the parasympathetic (PNS) is thickened and suppressed.

This part of our nervous system handles all of the automatic functions that we don’t even think about such as digestion of food, stimulating the acid to be released in your stomach, regulating the diameter of your lung airways, breathing rate, heart rate, pupil size, sweating, and much more.  It also directly and indirectly helps maintain body temperature, regulate your immune system, and control inflammation.  It has 2 components: the parasympathetic nervous system (PNS) and the sympathetic nervous system (SNS).  They work like a see-saw with each on either end.  Both are active at all times, but what actually happens depends on which one is in the driver’s seat or in control.

It helps to maintain your heart rate and breathing rate even if it’s not in control.  It controls your blood pressure.  Its main purpose is to protect you from harm and stress, the so-called fight or flight.  Best examples are if you almost got run over by a car or being chased by angry bees or dog, perhaps even during and after a heated argument.  Its function is to create the best possible conditions to either fight or run.  These could include dilating your pupils to allow light to enter the eye, increasing your heart rate and force of heart pumping, dilatating your airways to allow for harder and faster breathing, and supplying more blood flow to muscles of your arms and legs.  What does the SNS sacrifice to do all of this?  It shunts blood away from your digestive tract so that you won’t be digesting anything.  You won’t secrete anything: tears or saliva.  You will sweat though. 

Your body is meant to have the PNS in the driver seat most of the time. PNS allows your body to heal and take care of maintenance. SNS is like a wrecking ball to our inside, or better yet, a bull in a China shop (although, I can’t think of any time I would want that).  It’s great for short term when needed but not 24/7. You are being exposed to epinephrine (adrenaline) and cortisol all day long.  You will not only be on edge and have anxiety, but you will also have a difficult time shutting down to go to sleep.

The parasympathetic (PNS) is responsible for body maintenance and building new tissue, healing, controlling inflammation, and your immune system. This is your fun and relax system.  Keep the heart rate slow, reduce how fast you take breaths.  Digest all that food you ate.  The vagus nerve leaves your brain and travels throughout the body following the carotid artery and then the aorta.  It helps regulate most of digestive organs including the gallbladder.  It also controls the pacemaker of the heart or the sinoatrial node.  It even helps to decrease blood glucose by getting it turned into glycogen and stored in your liver. 

The vagus nerve is part of our parasympathetic (PNS). It modulates the immune system and inflammation. When it’s not working like it should, we see autoimmune conditions sprout up. We see chronic inflammation of nerves, muscles, and joints.

Initially this happens because of direct damage from the covid-19 virus to the supporting cells of the nerves of your nose and tongue, however this tends to heal within a few weeks after recovering from the virus. The smell and taste problems may spontaneously resolve after a few weeks, or they may turn into a lasting effect. The abnormality is fueled by stress and illnesses because both increase sympathetic drive.

There have been many different treatments proposed, but the ones that appear to be most successful and reliably reproduced are the stellate ganglion block and the external ear vagus nerve stimulation.  There are many other treatments for other symptoms of long covid.  For more info, go here.

It is a group of nerves located on each side of your cervical-thoracic vertebrae (the bones in your neck and chest part of your spine).  Signals from the brain stop there before going to the rest of your body.  Information for this ganglion is also relayed to the rest of the body including the face, brain, head, neck, arms, and chest.  You have one of these on each side of your neck.

It is shaped with points similar to a star so it was called a stellate.  It is similar to the word stellar.

It is a way to interrupt the signals going in and out from the stellate ganglion by numbing the ganglion with a local anesthetic such as lidocaine, ropivacaine, or bupivacaine.  This is performed under live ultrasound guidance at least in practice, but it can also be performed with fluoroscopy or live x-ray guidance.  This procedure is an injection but it is tolerated very well even awake.  We also block the C3 or C4 area which contains the superior cervical plexus and the sympathetic tract or road to the brain.  This is not technically part of the actual SGB, but has been shown to improve results by Dr. Eugene Lipov, MD.

Naltrexone comes in 50mg tablet form.  In order to produce 5 mg or less dosing, it must be compounded by a compound pharmacy.  Regular retail pharmacies are NOT able to do this.  

SGB stands for Stellate Ganglion Block.  It is an injection that is performed in the neck area to treat the dysautonomia cause of long covid.

We typically start with a right sided SGB block because most people appear to be right dominant when it comes to which tract is used more frequently. Both blocks can be safely done on the same day.

Assuming the SGB was safely performed by an experienced provider such as the ones we perform in our clinic, we expect and want to see the Horner’s syndrome.  This is a constellation of signs that show up almost immediately after the block is completed.  You may also feel a lump in your throat, hoarseness, loss of voice, or difficulty swallowing for the duration of the effects of the block.  This is not caused by the SGB, but by the inadvertent numbing of one of the vocal cord nerves called the recurrent laryngeal nerve.  This is not dangerous as long as both sides of your neck are numbed at the same time.

This syndrome is temporary and results from the decreased output of the sympathetic nervous system to your brain, face, head, neck, arms, and chest.  It causes a slight droopiness of the eye, redness in the white of the eye, a smaller pupil compared to the unblocked side, a stuffy nose on one side, and flushing of the eye, face, neck, ear, shoulder or arm.  The skin in these areas increases in temperature around 1 degree Celsius and appears flushed or red.  It is not necessary to see all of these, but I prefer to see at least 3 different signs to indicate that we did a good and solid sympathetic block.

No.  It is not dangerous and it is temporary when associated with an SGB.  We need to see this to verify that you actually received a good SGB and a sympathetic nervous system block.  You are not having a stroke or anything like that. 

 Some smooth muscles that we can’t control voluntarily are controlled by both the parasympathetic and sympathetic nervous system.  Others only have one or the other.  The droopy upper eyelid or ptosis is caused because we stop the functioning of one of such smooth muscle in your upper lid.  The pupil size becomes small under predominantly parasympathetic control when we take away the sympathetic nervous system influence.  Similarly, the nostril on the side of the blood becomes engorged and swells without the sympathetic nervous system influence. 

We don’t target the symptoms but the actual source of the problem, the dysautonomia.  What we have seen respond best to the SGB is smell and taste abnormalities including anosmia (no smell), parosmia (abnormal, and hyposmia, but not phantosmia), brain fog, anxiety, depression, and chronic fatigue. 

The Some providers talk about the SGB as a reset.  What exactly is reset?  It is a nerve block.  During the duration of the block, the sympathetic nervous system is off on one side.  During this time, the parasympathetic tone is elevated and there are regional blood flow changes in your brain, head, neck, and chest.  The combination of these things persist after the block wears off.

Because the sympathetic and parasympathetic are on opposite ends of a see-saw, when sympathetic tone decreases, the vagus nerve tone increases. 

Aside from the SGB, many of the maneuvers that help improve your vagus nerve tone also calm down your sympathetic response.

The easiest way is to use a TENS unit with adjustable frequency and pulse width.  TENS 7000 is inexpensive and easy to use.  You will also need 2 ear clips or 1 ear clip and 1 pad.  The pad can be placed on the shoulder or back of the neck.  The clip should be placed on the tragus of the ear.  If the ear clip is not staying, it can be placed on the cocha or the concha cymba.  The other clip can be placed anywhere comfortable on the ear.

Part of the reason is that your body is on constant alert thanks to the fight or flight constant state. 

It is a cognitive impairment.  It is a state of confusion, inability to focus, or inability to think straight.  It can also include memory loss and inability to recall words.

This is the timing in milliseconds or 1/1000th of a second between heart beats.  A higher number suggests a good functioning autonomic nervous system and parasympathetic nervous system.

These are mutually exclusive.  Orthostatic hypotension (OH) is a more severe form of POTS and involves drops in blood pressure in addition to the tachycardia (high heart rate) that occurs with POTS.

More information on Postural Orthostatic Tachycardia syndrome (POTS) .

Antibodies of one type created to treat many different conditions.  These bind to a receptor, binding protein, or another antibody.

It is an intravenous delivered pooled antibodies that are pooled from 1000’s of patients.  These are mainly used to treat antibody immunodeficiencies (low amounts of antibodies of IgG, IgM, and IgA).  These can also help with autoimmune conditions ,  neuropathies associated with long covid, and MCAS.

Most are monoclonal antibodies and bind an a specific interleukin or receptor.   These work for rheumatoid arthritis, asthma, eosinophilic diseases, eczema, psoriasis, ankylosing spondylitis, Crohn’s disease