Objective:

To educate awareness that Miller Fisher Syndrome (MFS) can present even without areflexia, ataxia, and albuminocytologic dissociation on lumbar puncture

Background:

Serum IgG antibody against GQ1b is very closely associated with acute postinfectious ophthalmoplegia in MFS and GBS. Anti-GQ1b IgG is thus closely associated with ophthalmoplegia and ataxia, and this group of diseases has been classified as anti-GQ1b IgG antibody syndrome. Although isolated ophthalmoplegia does not fall in any of the exact categories of anti-Gq1b syndrome, it still is within the spectrum and that treatment must be timely commenced as delay in diagnosis may lead to adverse clinical outcomes.

Design/Methods:

Case report.

Results:

An 81-year-old male with hypertension presented to primary care clinic with acute onset of diplopia. Two weeks prior, he had experienced an acute viral conjunctivitis accompanied with upper respiratory tract symptoms. He was admitted for further workup and concerns for intracranial pathology. His neurological exam is only pertinent for complete bilateral ophthalmoplegia. He had normal pupillary, ophthalmologic, motor, sensory, cerebellar, and reflex examination. Lumbar puncture yielded normal results without albuminocytologic dissociation. All imaging tests were normal. Extensive testing, including paraneoplastic evaluation, heavy metals, RPR, cryoglobulins, hepatitis panel, ANA, ANCA, CRP, NMO/AQP4 FACS, and MOG FACS, were all negative. Vitamin B1, B12, ACE, serum complements, and TSH were normal. Notably, the patient had strongly positive GQ1b IgG antibodies with titers >1:12800. He was treated with IVIg 0.4 g/kg for 5 days. At a follow-up visit one week post-discharge, his ophthalmoplegia had completely resolved.

Conclusions:

This case illustrates an atypical presentation of MFS with isolated ophthalmoplegia and no ataxia, areflexia, or albuminocytologic dissociation. Strongly positive anti-GQ1b IgG antibodies confirm the diagnosis. Clinicians should consider MFS in isolated ophthalmoplegia, especially with positive antibodies, and perform thorough evaluations to guide timely treatment and prevent complications.