An 81-year-old man with a history of chronic
pulmonary disease due to heavy smoking and
ischemic heart disease had been suffering for the past few years from chronic
constipation and
urinary incontinence and was receiving medication for cardiopulmonary symptoms and
urinary incontinence. He was admitted for repeated falling for a few months prior to admission. When put in the supine position, his blood pressure fell. He had bilateral pulmonary
rales, consistent with
lung disease, eccentricity of the left pupil (after
cataract surgery), constriction of the right pupil, and absence of the pupillary light reflex. There was generalized
hyperreflexia and a bilateral Babinski sign. He had normocytic, normochromic
anemia; B12,
folic acid and
ferritin were within normal ranges, ESR was rapid, there was hyperglobulinemia (
IgA and
IgG),
urea nitrogen and
creatinine were increased but returned to normal after
rehydration. ECG and chest X-ray were consistent with his cardiopulmonary status. Bone-marrow biopsy showed hypocellularity. IVP and barium enema were normal. Echocardiography revealed a possible old posterior wall
myocardial infarction. CT-scan showed moderate cerebral and cerebellar
atrophy, calcifications in the carotid and vertebral arteries, and small
infarcts in both hemispheres. At this point, after an extensive survey of the literature, the diagnosis of
Shy-Drager syndrome was proposed and proved by monitoring ECG and serum levels of
noradrenaline during postural changes. He was treated with Fluorinef and there were no more episodes of
postural hypotension. Several weeks after discharge he reported that he was feeling well and had not fallen since discharge.