Multisystem Atrophy Presenting with Hypercapnic Respiratory Failure

Magnetic resonance imaging clue to diagnosis; by showing bilateral middle cerebellar peduncles (MCP) signal abnormalities 1a-c]. Following stabilization of overall clinical status, extubation trial was given but patient continued to have intermittent stridulous breathing and needed re-intubation. On direct laryngoscopy, vocal cords were found to be in the midline position; hence, tracheostomy was done. Clinical features of cerebellar ataxia, orthostatic ABSTRACT Respiratory failure as the presenting feature is uncommon in neurodegenerative diseases. We report a case of 58-year-old male presenting as hypercapnic respiratory failure and stridor due to vocal cord paralysis accompanied with severe autonomic dysfunction, gait, and sleep changes. Examination showed cerebellar ataxia and autonomic dysfunction. Tracheostomy was necessary. Magnetic resonance imaging showed bilateral signal abnormality in middle cerebellar peduncles and favoring multisystem atrophy (MSA). The objective of this case report is to remind readers that MSA should be considered in differential diagnosis of unexplained respiratory failure, stridor, and vocal cord paralysis in appropriate clinical circumstances. Relevant literature is reviewed.