Journal of Neurology and Neuro Toxicology

A Typical Presentation of Miller Fisher Syndrome: A Case Report and Review of Literature

Author(s): Mohammed Madani, Pournamy Sarathchandran, Muna Lootah, Reem Al Suwaidi

Objective: Miller Fisher syndrome (MFS) is a well-recognized, but rare variant of Guillain-Barre syndrome (GBS) and is typically characterized by the classic triad of ophthalmoplegia, ataxia, and areflexia. Here we report a case with an atypical presentation of Miller Fisher syndrome that presented with an incomplete triad of ataxia and areflexia without ophthalmologia accompanied by mild proximal limb weakness and distal sensory involvement. 
Clinical presentation: A 65-years-old Arab man presented with a 2 week history of acute onset progressive unsteadiness of gait, associated with headache and numbness in all four extremities. He had history of a recent upper respiratory tract infection 2 weeks prior to the onset of his symptoms. He also had been vaccinated for the influenza one month back. Clinical examination showed intact higher mental functions, normal cranial nerves including extra-ocular movements and optic fundi, mild proximal muscle weakness in the lower limbs and graded distal sensory impairment for pin prick and joint position sense. There was generalized areflexia. There was mild appendicular ataxia and definite gait ataxia. CSF analysis showed albumin cytological dissociation. Nerve conduction study revealed mixed (axonal and demyelinating) motor polyneuropathy severely affecting lower limb nerves and cranial nerves. Ganglioside Profile was negative for GM1 and GQ1b antibodies. He improved completely after being treated with five sessions of plasma exchange. 
Conclusion: Miller Fischer syndrome should be considered in all patients who present with acute onset progressive ataxia, given its excellent response with treatment. A complete triad of ataxia, areflexia and ophthalmoplegia may not be present in all patients. High index of suspicion at presentation helps proper evaluation and early initiation of treatment to have excellent outcomes.

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