Objective: To highlight the importance of early recognition of the broader spectrum of clinical features of MSA and specially the sleep-related breathing disorders, as stridor.

Background: Laryngeal stridor is a non-motor feature that supports the diagnosis of multiple system atrophy (MSA) and its early occurrence might contribute to shorten survival. A consensus definition of stridor in MSA is lacking, and disagreement persists about its diagnosis, prognosis, and treatment.

Method: Case report with accompanying video and literature review.

Results: A 70-year-old female patient, presented a acinetic-rigid parkinsonism with right-sided asymmetry for 3 years. years. Initially, the patient responded favorably to levodopa treatment, but 3 years later, there was a pronounced motor worsening and loss of response to dopaminergic treatment, without the development of motor fluctuations. It was also reported frequent somniloquy and vivid dreams, as well as constipation and urgent urination. About 6 months after these non-motor symptoms, the patient reported episodes of loud breathing at night, which prompted a referral to a Sleep Disorders consultation. Three months later, she developed a rapidly progressive continuous daytime stridor, which had been ongoing for 3 days, and came to the emergency department (ED). In the ED, she had continuous stridor and dyspnea, requiring supplemental oxygen therapy, which did not respond to the therapy administered (corticosteroids, levodopa and biperiden). Paralysis of the vocal cords in adduction was observed, which prompted urgent tracheostomy with clinical improvement. During hospitalization, a complementary study allowed for the diagnosis of clinically established MSA-P. The videos of the observations in the ED and 1 year after the diagnosis was established will be presented.

Conclusion: This case reinforces the importance of multidisciplinary collaboration for adequate symptoms approach, by establishing the link between previous medical history and acute respiratory symptoms, particularly in pandemic time. Therefore, the prompted recognition of breathing disorders could be a window of opportunity for disease-modifying interventions.

Presented at the congress of the Portuguese society of movement disorders (March 17th, 2023)

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MDS Abstracts - https://www.mdsabstracts.org/abstract/acute-laryngeal-stridor-in-the-emergency-department-pandemic-or-additional-sign/