Multiple system atrophy (MSA) is a neurodegenerative disorder that usually 
presents clinically as a combination of parkinsonism, cerebellar syndrome and 
autonomic failure. Patients with MSA can present other clinical features, such 
as inspiratory stridor and rapid eye movement (REM) sleep behaviour disorder 
(RBD). We report a patient with pathologically confirmed MSA who presented with 
a longstanding history of stridor, RBD and autonomic disturbances but did not 
develop overt parkinsonism or cerebellar signs. This case illustrates that MSA 
may present clinically without its cardinal motor symptoms, and that stridor and 
RBD may be clues to recognise the disease in a patient with autonomic failure.