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He Sounds Like a Crow and Leaps from the Bed

Diagnosing multiple system atrophy (MSA) is a complex, interdisciplinary process due to the variation in symptom presentation. Diagnosing MSA requires following the case history; the early signs and symptoms are characteristic in many diseases while additional symptoms may seem unrelated or comorbid with other disorders. This case focuses on an individual diagnosed with Parkinson disease whose wife notices him gasping with a high-pitched sound during the night. A sleep study with audio/video recording determines this to be an inspiratory stridor, which confirms a diagnosis of MSA. Inspiratory stridor is due to either dystonia of the thyroarytenoid muscles or paralysis of the posterior cricoarytenoid muscles. Inspiratory stridor during sleep in an adult with parkinsonian symptoms warrants consideration of MSA, not Parkinson disease. Almost all patients with MSA have rapid-eye-movement (REM) sleep behavior disorder. A third of patients with MSA have inspiratory stridor, which typically occurs primarily in sleep. Inspiratory gasps awake and asleep are common in patients with MSA.