Case Report: Guillain-barre Syndrome Miller-fisher Variant Masking as Acute Cerebellar Stroke

Case Diagnosis: Guillain-Barre Syndrome (GBS), Miller Fisher Syndrome (MFS) suspected secondary to Immunization and Infection

Case Description or Program Description: A 92 year-old male who presented to the emergency room with worsening cough and weakness. One week prior he received Influenza vaccine. Patient with negative X-ray therefore discharged with Medrol dosepack. After one dose, patient presented worsening of lower extremity weakness, ataxia, dysmetria, and dysdiadochokinesia. Initial diagnosis was acute cerebellar infarction.

Setting: Tertiary care/hospitalization

Assessment/Results: CT found negative. Unable to perform MRI. CTA with small cerebellar stroke of undetermined age. Patients developed diplopia, ptosis, areflexia, and respiratory distress. Lumbar puncture could not be performed. EDX performed with sensory polyneuropathy, with loss of F wave in lower limb and temporal dispersion. Acute denervation potentials observed in facial, distal upper and lower extremities. Patient received IVIG for five days, with improvement. GQ-1b antibodies found positive. Once stable, patient transferred to Rehabilitation Ward.

Discussion (relevance): GBS is an immune mediated polyneuropathy with ascending sensorimotor deficits. Variants such as MFS have been documented with the classic triad of ataxia, ophthalmoplegia and areflexia in around 5-10% of all GBS cases. Causes can include complications from viral infections, diarrhea and, although rare, from vaccinations. In this case, patient with recent Influenza vaccine and acute symptom progression. Acute cerebellar strokes can also present with ataxia and weakness. The key factors to diagnosis in this case were classic triad presentation, history of infection and vaccination. Additionally, EDX proved to be an additional diagnostic tool with specific characteristics such as loss of F wave and temporal dispersion.

Conclusions: It is important to consider GBS-MFS as a differential diagnosis in patients who present with acute sensorimotor loss and symptoms associated with cerebellar dysfunction. It is also important to recognize the importance of EDX as a diagnostic tool, taking into consideration timing and clinical scenarios for early diagnosis and treatment.