Case Report
Multiple System Atrophy Type C and Its Neuropsychiatric Manifestations: Challenges in Diagnosis and Management-A Case Report
Kothekar M*, Parkar S, Ghodke J, Desai S, Dhar A and Purohit S
Department of Psychiatry, Vedantaa Institute of Medical Sciences, Dahanu, Palghar
*Corresponding author:Dr. Mansi Kothekar, Vedantaa Institute of Medical Sciences, Dahanu, Palghar. E-mail Id: dr.mansikothekar16@gmail.com
Article Information:Submission: 02/04/2026; Accepted: 16/04/2026; Published: 20/04/2026
Copyright: © 2026 Kothekar M, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Psychotic symptoms in Multiple System Atrophy (MSA) are uncommon, affecting approximately 5–10% of patients, and are frequently attributed to dopaminergic therapy or advanced disease. Early-onset psychosis intrinsic to MSA–C remains underrecognized and may result in misdiagnosis as a primary psychiatric disorder, delaying appropriate management.
Case Summary: A 54-year-old man with no prior psychiatric history presented with a one-week history of persecutory delusions and multimodal hallucinations. The psychosis was accompanied by executive dysfunction (MMSE 23/30; impaired Trail Making Test) and had emerged in the setting of progressive cerebellar ataxia, parkinsonism, and autonomic dysfunction (constipation, bladder dysfunction) — all antedating dopaminergic exposure. MRI demonstrated periventricular T2/FLAIR hyperintensities without the pathognomonic ‘hot cross bun’ sign. Based on consensus diagnostic criteria, a diagnosis of probable MSA–C was established. Olanzapine 5 mg nightly led to gradual resolution of psychosis without extrapyramidal worsening over two weeks.
Conclusion: This case illustrates that psychosis may be an early, intrinsic manifestation of MSA–C, preceding dopaminergic therapy and motor symptom dominance. Late-onset psychosis co-occurring with executive dysfunction and autonomic features should prompt systematic evaluation for neurodegenerative synucleinopathies. Recognition of underlying MSA has critical implications for antipsychotic selection and prognostication.
Case Summary: A 54-year-old man with no prior psychiatric history presented with a one-week history of persecutory delusions and multimodal hallucinations. The psychosis was accompanied by executive dysfunction (MMSE 23/30; impaired Trail Making Test) and had emerged in the setting of progressive cerebellar ataxia, parkinsonism, and autonomic dysfunction (constipation, bladder dysfunction) — all antedating dopaminergic exposure. MRI demonstrated periventricular T2/FLAIR hyperintensities without the pathognomonic ‘hot cross bun’ sign. Based on consensus diagnostic criteria, a diagnosis of probable MSA–C was established. Olanzapine 5 mg nightly led to gradual resolution of psychosis without extrapyramidal worsening over two weeks.
Conclusion: This case illustrates that psychosis may be an early, intrinsic manifestation of MSA–C, preceding dopaminergic therapy and motor symptom dominance. Late-onset psychosis co-occurring with executive dysfunction and autonomic features should prompt systematic evaluation for neurodegenerative synucleinopathies. Recognition of underlying MSA has critical implications for antipsychotic selection and prognostication.
Keywords:Multiple System Atrophy-C; Parkinsonism; Psychosis; Neurodegeneration; Late-onset psychosis; Synucleinopathy; Antipsychotic selection