Clinical Reasoning: A 63-Year-Old Female Patient Presenting With Orthostatic Hypotension and Ataxia.

A 63-year-old female patient presents with orthostatic hypotension and slowly progressive cerebellar ataxia. Neurologic examination revealed ataxia, pyramidal signs, and vibration/proprioception deficits. Neuroimaging showed diffuse white matter abnormalities, cord atrophy, and corticospinal tract involvement. This case highlights how a careful history, with special attention to tempo of symptoms and family history, combined with examination findings and neuroimaging can be used to reach a rare diagnosis.