Introduction:

A plethora of neurological deficits, with an incidence of 35-80%, have been found to be associated with the novel coronavirus (COVID-19) infection. Though several reports of Guillain-Barré syndrome, encephalitis, acute stroke, and anosmia have been established, Miller-Fisher syndrome has few cases linked to COVID 19 infection.

Case Description:

A 58-year-old male with a past medical history of hypertension, coronary artery disease, and diagnosed with COVID-19 two weeks prior, presented with hand and feet paresthesia’s, dysphagia, and difficulty walking. Initial evaluation demonstrated rapidly progressive ptosis, external ophthalmoplegia, facial weakness, tongue weakness, quadriparesis, areflexia, and bulbar dysfunction. A head and neck MR angiogram and brain MRI were unremarkable. Due to worsening hypoxia and respiratory failure, he was intubated. He underwent lumbar puncture with no evidence of infectious etiology on CSF analysis. He failed multiple weaning trials, and therefore underwent tracheostomy and PEG-tube placement. Further laboratory evaluation revealed elevated CK, ESR, and CRP. Serology included acetylcholine receptor blocking antibody <15, acetylcholine binding antibody of 0.00, MuSK antibody of 0.00, ganglioside GD1B antibody <1:100, ganglioside GQIB antibody titer 1:12800. He was diagnosed with Miller Fisher syndrome. He was given 5 days of IVIG, but also completed 5 sessions of plasmapheresis for persistent neurological symptoms. He returned to baseline functional status afterwards and was discharged to a rehabilitation center.

Discussion:

MFS is an acute, autoimmune peripheral neuropathy that is characterized by a triad of ophthalmoplegia, gait ataxia, and areflexia, and is also associated with anti-GQ1b antibodies. With few and sporadic known cases of COVID-19 associated MFS, it is difficult to draw a conclusion regarding the linkage between the two and if COVID-19 predisposes patients to MFS. As clinicians, it is imperative that we pay close attention to the neurologic symptoms associated with COVID-19 given the wide and clinically unestablished range of symptoms.