Hypertensive emergency with vasogenic cerebral edema following droxidopa initiation in pure autonomic failure

Pure autonomic failure (PAF) is characterized by neurogenic orthostatic hypotension and marked blood pressure (BP) lability. Droxidopa is widely used for symptomatic management and is generally well tolerated. We report a 60-year-old woman with advanced PAF who developed a hypertensive emergency with vasogenic cerebral edema shortly after initiation of low-dose droxidopa. This case highlights that severe hypertensive complications with reversible cerebral edema may occur even during low-dose droxidopa initiation in vulnerable patients with advanced autonomic dysfunction, underscoring the need for cautious dose titration and close BP monitoring.