Introduction: Multiple system atrophy (MSA) is a rare, progressive neurodegenerative disease that encompasses elements of cerebellar abnormalities, parkinsonism and autonomic dysfunction. Autonomic dysfunction classically manifests as orthostatic hypotension and is present in all forms of MSA. While MSA can only be definitively diagnosed post-mortem, a probable diagnosis is obtained clinically. There is no cure for MSA and patients are managed symptomatically. Different symptoms vary greatly in their response to pharmacotherapy, which makes management a challenge.
Case Report: We present the case of a 68-year-old female with probable MSA. The patient first presented to the emergency department of a community hospital complaining of dizziness when standing from a supine or seated position. On questioning it was learned that she was being followed at another hospital for possible MSA. Her orthostatic symptoms proved refractory to treatment with midodrine, so she was eventually started on fludrocortisone; this greatly reduced her symptoms. Early in her hospital stay, our patient also began experiencing urinary retention. This was effectively managed with catheterization; however, our patient’s hospital stay was prolonged due to a urinary tract infection and physical deconditioning.
Conclusion: This case illustrates some of the many challenges associated with both diagnosing and managing MSA. We wish to reinforce the high-level of clinical suspicion required to diagnose MSA and the therapeutic resilience and pharmacologic versatility necessary to manage symptoms.

Keywords: Autonomic dysfunction, Multiple system atrophy, Orthostatic hypotension, Shy-Drager syndrome