Anti-GQ1b-Negative Miller Fisher Syndrome with Acute Areflexic Mydriasis and Cholinergic Supersensitivity

Characteristics of pupil palsy in miller-fisher syndrome: case reports and review of the literature

Pupil palsy has been a frequent finding in Miller Fisher syndrome (MFS), but its clinical characteristics have not been clearly defined. The basis for differential diagnosis with other diseases with pupil palsy has also remained vague. We report cases of four MFS patients with bilateral pupil palsy and specify pupil characteristics of light-near dissociation (LND), cholinergic super-sensitivity, vermiform movements, and prognosis. We conducted a literature review to compare with our cases and investigate common findings of pupil palsy in MFS patients. We suggest that the acute generalized pupil palsy without vermiform movements can serve as a key finding for the diagnosis of pupil palsy associated with MFS. However, the presence of LND and cholinergic super-sensitivity was not distinctive clinical findings in MFS patients who had pupil palsy and did not prove useful for differential diagnosis. The prognosis of pupil palsy in MFS patients was good in our 4 cases and the literature review.

Miller Fisher syndrome with bilateral vocal cord paralysis: a case report

Background

Miller Fisher syndrome is a variant of acute inflammatory demyelinating polyneuropathy classically characterized by ataxia, ophthalmoplegia, and areflexia. Miller Fisher syndrome can present with uncommon symptoms such as bulbar, facial, and somatic muscle palsies and micturition disturbance.

Case presentation

We describe the case of a 76-year-old white man with new-onset ataxia, stridor, areflexia, and upper and lower extremity weakness who required intubation at presentation. An initial work-up including imaging studies and serum tests was inconclusive. Eventually, neurophysiological testing and cerebrospinal fluid analysis suggested a diagnosis of Miller Fisher syndrome. Our patient responded to treatment with intravenous immunoglobulin and supportive therapy.

Conclusion

The occurrence of acute or subacute descending paralysis with involvement of bulbar muscles and respiratory failure can often divert clinicians to a diagnosis of neuromuscular junction disorders (such as botulism or myasthenia gravis), vascular causes like stroke, or electrolyte and metabolic abnormalities. Early identification of Miller Fisher syndrome with appropriate testing is essential to prompt treatment and prevention of further, potentially fatal, deterioration.