Miller fisher syndrome

1. Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM

2. A 57 years old diabetic right handed gentleman,
hailing from Mirpur, got admitted in BIRDEM
General Hospital on 11th
March,14 with the
complaints of-
• Double vision for 6 days
• Difficulty in walking for 4 days

3. According to the statement of the patient, he
was reasonably well 6 days back. Then he
developed double vision which was sudden
on onset, constant, more marked on eye
movement & not associated with diuranal
variation. He also had complaints of
headache which was sudden on onset, global,
dull aching in nature, mild to moderate in
severity. It was not associated with radiation,
vomiting. There was no exacerbating factors
& it was relieved with medication.

4. • He also had complaints of difficulty in walking
for last 4 days which was gradual on onset due
weakness of lower limbs progressing to upper
limbs rapidly. It was associated with
numbness of limbs. There was no associated
back pain, vertigo on standing, palpitation,
shortness of breath, swallowing difficulties,
slurring of speech. He doesn't give h/o cough
& diarrhea.

5. H/O Present illness
He consulted an endocrinologist for these
problems as he assumed that it might be due
to high blood sugar. He was advised for CT
scan & subsequent MRI of brain &
diagnosed as a case of DMT2, Acute
ischaemic stroke, cranial polyangitis due to
diabetes with DPN. He was treated with
insulin, aspirin, atorvastatin & vtamin B
complex. He got admitted in Neurology,
BIRDEM as he was not improving.

6. CT Scan of Brain

7. CT Scan of Brain

12. H/O past illness:
Nothing contributory
Socioeconomic history:
He belongs to a middle class family
Personal history:
He is non alcoholic, non smoker

13. Family history:
Nothing significant
Treatment history:
Insulin
Tab. Vit B complex
Tab. Aspirin
Tab. Atorvastatin

14. General examination:
Appearance: ill looking, anxious
Built: average
Decubitus: on choice
Anaemia
Jaundice
Cyanosis
Oedema
Dehydration
Clubbing
Koilonychia
Leukonychia
Absent

15. General examination:
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Skin pigmentation & body hair distribution: normal
Pulse: 78 b/min
BP: 120/70 mmHg
Temp:98 F
RR: 16 breaths/min

16. • Higher psychic function : Conscious, Oriented
• Speech: Normal
• Cranial nerves :
Bilateral complete opthalmoplegia with right
sided lower motor type VII nerve palsy
• Fundus: Normal
• GCS: 15/15
NERVOUS SYSTEM EXAMINATION

18. Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Normal Normal
Tone Decreased Decreas
ed
Decreased Decreased
Power 3/5 3/5 3/5 3/5
Involuntary
movement
Absent Absent Absent Absent
MOTOR FUNCTION:

19. Reflex B T S K A Abd Plantar
Right Abs
ent
Abs
ent
Abse
nt
Abse
nt
Ab
sen
t
Absent Flexor
Left Abs
ent
Abs
ent
Abse
nt
Abse
nt
Ab
sen
t
Absent
Flexor

20. Sensory system:
Pain Temp Touch Vibratio
n
Position
sense
Right upper
limb
Intact
Right lower
limb
Left upper
limb
Left lower
limb

21. • Sign of Meningeal irritation - Absent
• Cerebellar sign : Absent
• Gait: Ataxic

22. Systemic examinations
Other systemic examination was normal

23. A 57years old diabetic gentleman got admitted
in neurology with the complaints of double
vision which was sudden on onset, more
marked on eye movement & not associated
with diurnal variation. He also had complaints
of headache which was sudden on onset,
global, dull aching in nature, mild to moderate
in severity. It was not associated with radiation,
vomiting.
Salient feature

24. Salient feature
He also had complaints of difficulty in walking
for last 4 days which was gradual on onset due
to weakness of lower limbs progressing to upper
limbs rapidly. It was associated with numbness
of limbs. There was no associated back pain,
vertigo on standing, palpitation, shortness of
breath, swallowing difficulties, slurring of
speech. He doesn't give h/o cough & diarrhea.

25. • On examination, he was anxious, ill looking,
bilateral complete opthalmoplegia with right
sided lower motor type VIIth nerve palsy,
Generalized hypotonia, diminished muscle
power, generelized areflexia with bilateral
planter flexor. All modalities of sensation were
intact with ataxic gait.

26. Provisional diagnosis
• Guillain-Barre Syndrome(Miller Fisher
Variant)
• Diabetes Mellitus Type 2
• Leukoaraiosis / Periventricular white
matter disease

27. Differential diagnosis
• Mononeuritis cranial multiplex due to?
Vasculitis/Diabetes

28. Investigations
CBC:
Hb % - 14.2
WBC -6800 cu/mm
Neu-65 %
Lymph- 30%
Mono -3 %
Eosino- 1.1%
Platelet- 195000
ESR- 30mm in 1st
hour

29. S. Electrolytes
Na-137 mmol/l
K-4.5 mmol/l
Cl: 106 mmol/l
HCO3: 26 mmol/l
Ca- 9.3 mmol/l
Mg- 0.9 mmol/l
Phosphate-3.7

30. Lipid profile:
TG: 176 mg/dl
T. Chol : 164 mg/dl
LDL: 95 mg/dl
HDL:36 mg/dl
LFT:
ALT: 34 iu/L
AST: 37 iu/L
RFT:
S. Creatinine: 0.8mmol/l
S Urea: 29 mmol/l
HbA1c: 7.2%

31. Sugar - Nil
Albumin – Nil
Ketone- Nil
Epi. cell: A few /HPF
Pus cell: 1-2 /HPF
RBC: Nil
URINE R/M/E

32. Chest X-Ray
NORMAL

33. ECG
Normal

34. Nerve conduction study
• Pure motor polyneuropathy-
• Possibilities are:
• AMAN
• Other motor polyradiculoneuroapthy

35. CSF study
• Appearance: clear
• Protein: 66g/L
• Sugar: 4.2mmol/L( Corresponding blood
glucose-6.8 mmol/l)
• Cell count:
• Total WBC : Nil
• Total RBC: Nil
• Bacterial antigen: Negative

36. Final diagnosis:
• Guillain-Barre Syndrome(Miller Fisher Variant)
• Diabetes Mellitus Type 2
• Leukoaraiosis / Periventricular white matter
disease

37. Treatment:
Short acting insulin
I/V immunoglobulin
Daily physiotherapy
Vitamin B
Patient was counseled about Course and
prognosis of the disease

38. Hospital course
• He showed significant improvement with
treatment.
• Gait & opthalmoplegia was improved

39. Follow UP
Patient was advised to follow up in Neurology
after 1 month for further clinical evaluation &
management.