(Kiosk 3) A Rare Case of Miller Fisher Syndrome and Implications on Inpatient Rehabilitation

Case Diagnosis: Miller Fisher Syndrome

Case Description or Program Description: A 16 year old male presented to the emergency department with two of days headache, ophthalmoparesis, ataxia, and slurred speech. Initial workup included non-contrasted head CT/CTA, lumbar puncture, brain MRI, and laboratory evaluation. He required intubation for respiratory failure. Workup and presentation were concerning for Miller Fisher variant of Guillain-Barré syndrome. He was treated with IV steroids and IVIG. He was extubated and PM&R was consulted for evaluation of functional deficits. He was admitted to inpatient rehabilitation and subsequently had severe neuropathic pain, continued cranial nerve palsies, papilledema, and autonomic dysfunction which required multidisciplinary evaluation and management.

Setting: Inpatient Rehabilitation Unit

Assessment/Results: The patient had severe neuropathic pain which responded well to gabapentin, amitriptyline, and therapeutic massage. He complained of palpitations and was found to be in first and second degree Mobitz type 1 AV node block, likely related to autonomic dysfunction. This was evaluated and monitored with assistance from Cardiology with no further symptoms. Regarding ocular symptoms, he was evaluated by Ophthalmology and in addition to opthalmoparesis had papilledema related to increased intracranial pressure. He was started on diamox and followed closely outpatient. Functionally he improved significantly in his rehabilitation course with intensive physical therapy and occupational therapy.

Discussion (relevance): This patient experienced rare manifestations of Miller Fisher syndrome including respiratory failure, papilledema, and autonomic dysfunction. This case highlights the importance of comprehensive evaluation to quickly identify and manage potentially life threatening complications. Effective pain management was critical in a successful rehabilitation course.

Conclusions: Miller Fisher syndrome is a rare variant of Guillain Barre syndrome which may present with cranial nerve palsies, respiratory dysfunction, papilledema, ataxia, areflexia, neuropathic pain, autonomic dysfunction, and weakness. Initial treatment includes supportive care as well as IV steroids, IVIG and rehabilitation to address functional deficits. Most patients recover in 6 months with no residual deficits.