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Chow BJ, Raharja A, Dahir R, Khaier A, Posner M. Understanding the diagnostic challenges of Miller Fisher syndrome in children: a case report from an ophthalmological perspective. Br J Hosp Med (Lond) 2024; 85:1-5. [PMID: 39212552 DOI: 10.12968/hmed.2024.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
We report a case of a 6-year-old boy with autism spectrum disorder presenting with new-onset squint and 'ptosis' following a recent infection. Clinical examination revealed ataxia and areflexia alongside a dilated pupil poorly reactive to light. Subsequently, his eye movements deteriorated to near-complete ophthalmoplegia at 1-week review. Further investigations inclusive of a magnetic resonance imaging (MRI) brain scan, a computed tomography (CT) venogram and a lumbar puncture were conducted to consider and rule out differential diagnoses. Cerebrospinal fluid analysis revealed an albuminocytologic dissociation. The clinical triad of progressive ophthalmoplegia, areflexia and areflexia alongside albuminocytologic dissociation led to the diagnosis of Miller Fisher syndrome. The patient was commenced on intravenous immunoglobulin and his symptoms showed significant improvement. We use this interesting case to provide context for key learning points about diagnosing Miller Fisher syndrome in children.
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Affiliation(s)
- Bing Jie Chow
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Antony Raharja
- Department of Ophthalmology, Queen's Hospital, Barking, Havering and Redbridge University NHS Hospital Trust, London, UK
| | - Ruqiya Dahir
- Department of Ophthalmology, Queen's Hospital, Barking, Havering and Redbridge University NHS Hospital Trust, London, UK
| | - Ayman Khaier
- Department of Ophthalmology, Queen's Hospital, Barking, Havering and Redbridge University NHS Hospital Trust, London, UK
- Department of Accident and Emergency, Moorfields Eye Hospital, London, UK
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Jha S. Isolated ophthalmoplegia with alternating aniscoria in anti-GQ1b negative syndrome. Acta Neurol Belg 2024; 124:1423-1424. [PMID: 38265634 DOI: 10.1007/s13760-024-02482-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 01/18/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Shreyashi Jha
- Department of Neurology, Institute of Neurosciences, Kolkata, 700017, India.
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Noioso CM, Bevilacqua L, Acerra GM, Valle PD, Serio M, Pecoraro A, Rienzo A, De Marca U, De Biasi G, Vinciguerra C, Piscosquito G, Toriello A, Tozza S, Barone P, Iovino A. The spectrum of anti-GQ1B antibody syndrome: beyond Miller Fisher syndrome and Bickerstaff brainstem encephalitis. Neurol Sci 2024:10.1007/s10072-024-07686-3. [PMID: 38987510 DOI: 10.1007/s10072-024-07686-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Since the initial identification of Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE),significant milestones have been achieved in understanding these diseases.Discoveries of common serum antibodies (IgG anti-GQ1b), antecedent infections, neurophysiological data, andneuroimaging suggested a shared autoimmune pathogenetic mechanism rather than distinct pathogenesis, leadingto the hypothesis that both diseases are part of a unified syndrome, termed "Fisher-Bickerstaff syndrome". The subsequent identification of atypical anti-GQ1b-positive forms expanded the classification to a broader condition known as "Anti-GQ1b-Antibody syndrome". METHODS An exhaustive literature review was conducted, analyzing a substantial body of research spanning from the initialdescriptions of the syndrome's components to recent developments in diagnostic classification and researchperspectives. RESULTS Anti-GQ1b syndrome encompasses a continuous spectrum of conditions defined by a common serological profilewith varying degrees of peripheral (PNS) and central nervous system (CNS) involvement. MFS and BBE represent theopposite ends of this spectrum, with MFS primarily affecting the PNS and BBE predominantly involving the CNS.Recently identified atypical forms, such as acute ophthalmoparesis, acute ataxic neuropathy withoutophthalmoparesis, Guillain-Barré syndrome (GBS) with ophthalmoparesis, MFS-GBS and BBE-GBS overlap syndromes,have broadened this spectrum. CONCLUSION This work aims to provide an extensive, detailed, and updated overview of all aspects of the anti-GQ1b syndromewith the intention of serving as a stepping stone for further shaping thereof. Special attention was given to therecently identified atypical forms, underscoring their significance in redefining the boundaries of the syndrome.
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Affiliation(s)
- Ciro Maria Noioso
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy.
| | - Liliana Bevilacqua
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Gabriella Maria Acerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Paola Della Valle
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Marina Serio
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Agnese Pecoraro
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Annalisa Rienzo
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Umberto De Marca
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Giuseppe De Biasi
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Claudia Vinciguerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Giuseppe Piscosquito
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Antonella Toriello
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Stefano Tozza
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Paolo Barone
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Aniello Iovino
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
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Habib AA, Waheed W. Guillain-Barré Syndrome. Continuum (Minneap Minn) 2023; 29:1327-1356. [PMID: 37851033 DOI: 10.1212/con.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article summarizes the clinical features, diagnostic criteria, differential diagnosis, pathogenesis, and prognosis of Guillain-Barré syndrome (GBS), with insights into the current and future diagnostic and therapeutic interventions for this neuromuscular syndrome. LATEST DEVELOPMENTS GBS is an acute, inflammatory, immune-mediated polyradiculoneuropathy that encompasses many clinical variants and divergent pathogenic mechanisms that lead to axonal, demyelinating, or mixed findings on electrodiagnostic studies. The type of antecedent infection, the development of pathogenic cross-reactive antibodies via molecular mimicry, and the location of the target gangliosides affect the subtype and severity of the illness. The data from the International GBS Outcome Study have highlighted regional variances, provided new and internationally validated prognosis tools that are beneficial for counseling, and introduced a platform for discussion of GBS-related open questions. New research has been undertaken, including research on novel diagnostic and therapeutic biomarkers, which may lead to new therapies. ESSENTIAL POINTS GBS is among the most frequent life-threatening neuromuscular emergencies in the world. At least 20% of patients with GBS have a poor prognosis and significant residual deficits despite receiving available treatments. Research is ongoing to further understand the pathogenesis of the disorder, find new biomarkers, and develop more effective and specific treatments.
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Harrison A, Mudhar O, Yoo J, Rampal M. Diplopia in a patient presenting with "blurred vision": a case report. J Med Case Rep 2023; 17:402. [PMID: 37679826 PMCID: PMC10485954 DOI: 10.1186/s13256-023-04089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Myasthenia gravis is an autoimmune condition affecting the neuromuscular junction and causing muscle weakness along with fatigue (myasthenia). When the clinical manifestations of myasthenia gravis are isolated to the eye muscles, only causing weak eye movements, it is referred to as ocular myasthenia gravis, which can mimic a 1 and ½ syndrome. CASE PRESENTATION An African-American female in her fifties with past medical history of hypertension presented to our outpatient clinic with complaints of blurred vision for two weeks. Her symptoms were associated with facial discomfort and a generalized headache. On physical examination upon her initial presentation, there was demonstratable swelling of the left upper eyelid with drooping. Her extraocular movements revealed defects with the abduction and adduction of the right eye, and the left eye would not adduct, although the outward movement was normal. The left eye failed to lift/elevate completely when looking upwards, a pseudo 1 and ½ syndrome. A positive Cogan lid twitch was also noticed. Imaging of the brain and orbit ruled out central causes. Diagnosis of ocular myasthenia gravis was made in accordance with positive anti-acetylcholine receptor antibodies. With 120 mg pyridostigmine oral dose, the patient experienced improvement subjectively and objectively, and the patient was discharged on oral pyridostigmine and prednisone. Six months later, with prednisone having been tapered off, the patient developed a myasthenic crisis and was treated with plasmapheresis and intravenous immunoglobulins. After recovering from the myasthenic crisis, efgartigimod infusions were instituted, which helped our patient restore normal life. CONCLUSION Our patient who presented with "blurred vision" was discovered to have binocular diplopia due to significant dysconjugate eye movements. After diligently ruling out central etiologies, we concluded that her presentation was due to a peripheral etiology. Her serologies and her presentation helped confirm a diagnosis of ocular myasthenia gravis. Also, as in most cases, our patient also progressed to develop generalized myasthenia gravis while on pyridostigmine. Efgartigimod infusions instituted after our patient recovered from a myasthenic crisis have helped her restore a normal life.
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Affiliation(s)
- Anil Harrison
- Department of Internal Medicine, UCF/HCA, Pensacola, FL, USA
| | - Onkar Mudhar
- Internal Medicine Resident, Department of Internal Medicine, Touro University, Stockton, CA, USA
| | - Jun Yoo
- Department of Internal Medicine, UCF/HCA, Pensacola, FL, USA.
| | - Mayank Rampal
- Department of Internal Medicine, UCF/HCA, Pensacola, FL, USA
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Shaath DS, Scheidt AF, Stiff HA. Sudden-Onset Bilateral Mydriasis in a Young Girl. JAMA Ophthalmol 2023; 141:792-793. [PMID: 37382931 DOI: 10.1001/jamaophthalmol.2023.2585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
A 3-year-old girl presented to the emergency department with 1 day of abnormal gait and bilateral mydriasis. Repeat magnetic resonance imaging demonstrated diffuse enhancement of the lower thoracic and cauda equina nerve roots and enhancement of the left oculomotor nerve.
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Affiliation(s)
- Deena S Shaath
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee
| | - Abigail F Scheidt
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee
| | - Heather A Stiff
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee
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Jebaraj AP, Swiston CJ, Vegunta S, Warner JEA. Isolated Bilateral Internal Ophthalmoplegia as an Atypical Initial Presentation of anti-GQ1b Antibody Syndrome. J Neuroophthalmol 2022; 42:e389-e390. [PMID: 34310460 DOI: 10.1097/wno.0000000000001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Abigail P Jebaraj
- Department of Neuro-Ophthalmology, John A Moran Eye Center, Salt Lake City, Utah
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Lee JH, Jang Y, Kim SJ, Jung JH. Characteristics of pupil palsy in miller-fisher syndrome: case reports and review of the literature. Neurol Sci 2021; 42:5213-5218. [PMID: 33825117 DOI: 10.1007/s10072-021-05157-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/26/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jang Ho Lee
- Seoul National University College of Medicine, Seoul, South Korea
| | - Yeonji Jang
- Department of Ophthalmology, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, South Korea
| | - Seong-Joon Kim
- Department of Ophthalmology, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, South Korea
| | - Jae Ho Jung
- Department of Ophthalmology, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, South Korea.
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Agirre-Beitia G, Moreno-Estébanez A, González-Pinto T, Díaz-Cuerv I. Non-reactive pupils as early sign of Miller Fisher syndrome. CURRENT JOURNAL OF NEUROLOGY 2020; 19:152-153. [PMID: 38011405 PMCID: PMC8185588 DOI: 10.18502/cjn.v19i3.5430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/20/2020] [Indexed: 11/24/2022]
Abstract
The article's abstract is not available.
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Faster Recovery of Internal Ophthalmoplegia than External Ophthalmoplegia in a Miller Fisher Variant of Guillain-Barre Syndrome. Case Rep Ophthalmol Med 2020; 2020:7258327. [PMID: 32328331 PMCID: PMC7174959 DOI: 10.1155/2020/7258327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/18/2020] [Indexed: 11/18/2022] Open
Abstract
We present a case of classic Miller Fisher Syndrome (MFS) variant of Guillain-Barre Syndrome (GBS) with detailed description in the difference between the internal and external ophthalmoplegia. They are different in their onset, duration, and recovery.
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Abstract
PURPOSE OF REVIEW This article will update and review the Miller Fisher variants (MFV) of Guillain-Barré syndrome (GBS) including the clinical presentation, diagnostic testing, and treatment. RECENT FINDINGS Although the diagnosis of GBS and MFV can be made on clinical grounds, cerebrospinal fluid (CSF) analysis, nerve conduction studies, imaging (e.g. ultrasound and MRI), and serologic testing can help to confirm the diagnosis. Some patients may need immunotherapy with either intravenous immunoglobulin (IVIg) or plasma exchange, and recent studies suggest that complement inhibition combined with IVIg could be of benefit, but further studies are needed to prove efficacy. SUMMARY GBS is characterized by an acute, ascending polyneuropathy, ataxia, areflexia, and CSF albuminocytologic dissociation. The MFV of GBS is associated with ophthalmoplegia. Clinicians should have high index of suspicion for MFV of GBS in patients with acute ophthalmoplegia in order to establish the diagnosis, perform appropriate evaluation, and start treatment. SDC VIDEO LINK:.
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Sim BNH, Joseph JP. Forme fruste anti-GQ1b-negative Miller Fischer syndrome masquerading as posterior circulation stroke. J R Coll Physicians Edinb 2019; 49:304-306. [PMID: 31808458 DOI: 10.4997/jrcpe.2019.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Miller Fischer syndrome (MFS) is a variant of Guillain-Barré syndrome first described in 1956 and is characterised by the clinical triad of ophthalmoplegia, ataxia and areflexia. However, since its discovery, forme fruste and overlapping syndrome have been described. A forme fruste of MFS implies an attenuated form where not all of the clinical triad are present. In this report, a case of MFS is highlighted that was mistakenly treated as posterior circulation stroke, as well as the challenges faced in reaching the correct diagnosis and hence the appropriate treatment.
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Affiliation(s)
- Benjamin Ng Han Sim
- Neurology Department, Hospital Kuala Lumpur, 23, Jalan Pahang, 50586 Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia,
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Escorcio-Bezerra ML, Manzano GM, Bichuetti DB, Nunes KF, Correa DSA, Oliveira ASB, Baeta AM. Tonic pupils: an unusual autonomic involvement in chronic inflammatory demyelinating polyneuropathy (CIDP). Neurol Sci 2019; 40:1725-1727. [PMID: 30997592 DOI: 10.1007/s10072-019-03890-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuropathy (CIDP) is a neuropathy which affects mainly large myelinated axons and has a typically mild autonomic dysfunction mainly from postganglionic nerve fiber involvement. CASE REPORT We report here an acute onset CIDP initially diagnosed as Guillain-Barré syndrome (GBS), unresponsive to treatment with intravenous immunoglobulin (IVIg), which later responded to plasmapheresis and corticoids. The patient had a markedly distal demyelination, prominent cranial nerve involvement and, interestingly, bilateral fixed dilated pupils. Despite complete clinical recovery, this neurological sign remained. CONCLUSIONS Tonic pupils have previously been described in different neurologic conditions, including GBS, but not yet in acute onset CIDP or in variants with predominantly distal demyelination. It differs from the classical Adie's pupil because it lacks the light-near dissociation. This case report expands the range of possible autonomic signs in acute onset CIDP, which could help physicians establish optimal treatment strategies earlier on.
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Affiliation(s)
- Marcio Luiz Escorcio-Bezerra
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil.
| | - Gilberto Mastrocola Manzano
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil
| | - Denis Bernardi Bichuetti
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil
| | - Karlo Faria Nunes
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil
| | - Daniele Sales Alves Correa
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil
| | - Acary Souza Bulle Oliveira
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil
| | - Alex Machado Baeta
- Department of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, São Paulo, SP, 04039-002, Brazil
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Ramakrishnan S, Kulkarni G, Mustare V. Neuro-ophthalmological manifestations in three cases of Miller Fisher syndrome and a brief review of literature. Neurol India 2015; 63:975-7. [DOI: 10.4103/0028-3886.170075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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