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Miller fisher syndrome
A 57-year-old diabetic man presented with double vision for 6 days and difficulty walking for 4 days. On examination, he had bilateral eye muscle paralysis, weakness of the limbs, reduced reflexes, and an unsteady gait. Tests showed a motor nerve disorder and diabetes complications. He was diagnosed with Guillain-Barré syndrome (Miller Fisher variant), diabetes mellitus type 2, and white matter brain changes. He received treatment and showed improvement in the hospital.
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Miller fisher syndrome
- 1. Dr. Md RashedulIslam FCPS, MRCP(UK) Registrar, Neurology, BIRDEM
- 2. A 57 yearsold 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 thestatement 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 alsohad 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 Heconsulted 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 ofBrain
- 7. CT Scan ofBrain
- 12. H/O past illness: Nothingcontributory Socioeconomic history: He belongs to a middle class family Personal history: He is non alcoholic, non smoker
- 13. Family history: Nothing significant Treatmenthistory: Insulin Tab. Vit B complex Tab. Aspirin Tab. Atorvastatin
- 14. General examination: Appearance: illlooking, 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 psychicfunction : 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. ULLt. 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 TS 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 TempTouch Vibratio n Position sense Right upper limb Intact Right lower limb Left upper limb Left lower limb
- 21. • Sign ofMeningeal irritation - Absent • Cerebellar sign : Absent • Gait: Ataxic
- 22. Systemic examinations Other systemicexamination was normal
- 23. A 57years olddiabetic 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 alsohad 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-BarreSyndrome(Miller Fisher Variant) • Diabetes Mellitus Type 2 • Leukoaraiosis / Periventricular white matter disease
- 27. Differential diagnosis • Mononeuritiscranial 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-4.5mmol/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: 176mg/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
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- 33.
- 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-BarreSyndrome(Miller Fisher Variant) • Diabetes Mellitus Type 2 • Leukoaraiosis / Periventricular white matter disease
- 37. Treatment: Short acting insulin I/Vimmunoglobulin Daily physiotherapy Vitamin B Patient was counseled about Course and prognosis of the disease
- 38. Hospital course • Heshowed significant improvement with treatment. • Gait & opthalmoplegia was improved
- 39. Follow UP Patient wasadvised to follow up in Neurology after 1 month for further clinical evaluation & management.