Atypical Descending Paralysis in Miller Fisher Syndrome: A Rare Variant of Guillain-Barre Syndrome

Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome (GBS) which usually presents with descending paralysis. Common symptoms are ophthalmoplegia, ataxia, and areflexia. Our case presented with an atypical presentation. A 52-year old lady presented to the neurology outpatient department with frequent falls, blurring and doubling of vision and difficulty swallowing. These symptoms followed mild non-bloody diarrhea for two weeks ago. She had bilateral ptosis, lateral gaze palsy in both eyes, absent gag and cough reflex; she was unable to walk in a straight line and had right-hand grip weakness. Other motor and sensory examination were normal. She was admitted, kept under observation and investigated accordingly. Cerebrospinal fluid (CSF) analysis showed albuminocytologic dissociation. Nerve conduction studies showed slowed conduction in abducent, glossopharyngeal, vagus, and the right ulnar nerve. Blood analysis showed antiganglioside GQ1b antibodies; hence, the diagnosis of MFS, a variant of GBS, was made. Empirically plasmapheresis and then after confirmation intravenous immunoglobulins (IVIG) were used as treatment options. She recovered gradually within four weeks.