Diagnosing it Early: A Guillain-Barré Variant That’s Hard to Catch- Miller Fisher Syndrome. A Case Report

Case Diagnosis: 60 yo male with Miller Fisher Syndrome

Case Description or Program Description: A lumber yard worker sustained a penetrating neck injury from a lodged piece of wood, resulting in a left carotid artery dissection. He received treatment, including a Tdap vaccine, and recovered quickly. However, within two weeks of discharge, he experienced multiple falls due to progressive leg weakness. Hospital evaluation revealed bilateral upper extremity weakness, absent reflexes, ataxia, and ophthalmoplegia. Despite a negative GQ1b antibody test, EMG and nerve conduction studies showed diffuse demyelinating sensory-motor neuropathy. Given his clinical presentation, Miller Fisher Syndrome (MFS) was suspected, and he was treated with intravenous immunoglobulin (IVIG) at 400 mg/kg for five days.

Setting: Acute Rehabilitation Hospital

Assessment/Results: Our patient exhibited the classic triad of ophthalmoplegia, ataxia, and areflexia, supported by characteristic electrophysiological findings. Despite negative GQ1b serology (present in ~85% of cases), IVIG treatment proceeded based on electromyography results. The electromyographic study completed was abnormal revealing both lower extremities demonstrated features consistent with a demyelinating polyneuropathy. The left ulnar distal motor latency is prolonged with borderline amplitude and decreased persistence of the F wave. Sensory nerve conduction studies demonstrated decreased amplitudes and prolonged latencies.

Discussion (relevance): Early detection and intervention improve recovery and reduce complications. IVIG is most effective when initiated within two weeks of symptom onset in suspected MFS cases. This case was unique, as MFS may have been triggered by a traumatic neck injury and recent Tdap vaccination—an uncommon association. While MFS is typically linked to Campylobacter jejuni, Haemophilus influenzae, or recent COVID-19 vaccination, its connection to trauma or Tdap remains unclear and underreported.

Conclusions: This case underscores the need for early recognition and treatment of MFS, especially in atypical presentations. Electrodiagnostic studies were crucial for timely diagnosis and management despite negative serology.