A 47-Year-Old With Diplopia, Limb Tingling, and Imbalance

Sujatha R. Borra, MD; Rahul R. Borra; Darshan Rola; Neal T. Patel


August 03, 2021


A comprehensive differential diagnosis was developed on the basis of the patient's presentation. Of the conditions in the differential diagnosis, the most plausible were Guillain-Barré syndrome, Miller Fisher syndrome, Charcot-Marie-Tooth (CMT) disease, myasthenia gravis, and Clostridium botulinum poisoning.

The patient's symptoms raised suspicion for a demyelinating disease. The lack of pertinent positive findings on both laboratory tests and imaging studies suggested that his previous mild respiratory tract infection may have contributed to his presentation. Electromyography of his lower extremities bilaterally revealed slowed conduction velocity. These findings, in addition to his presenting symptoms and his history of a respiratory tract infection, pointed to a diagnosis of Miller Fisher syndrome, a rare variant of Guillain-Barré syndrome. To confirm this diagnosis, serologic testing was conducted. The results came back positive for anti-GQ1b IgG antibodies, which are pathognomonic of Miller Fisher syndrome.

Guillain-Barré syndrome is an acute demyelinating neuropathy that typically presents after an acute bacterial or viral infection. The pathogen that is best known to predispose to this condition is Campylobacter jejuni; however, influenza viruses, cytomegalovirus, Mycoplasma pneumoniae, and Epstein-Barr virus can all potentially lead to this syndrome. Although infection with these pathogens is relatively common, Guillain-Barré syndrome is not. The annual US incidence is 1.2-3 per 100,000 inhabitants, which makes it the most common cause of acute flaccid paralysis in the United States.[1]

Guillain-Barré syndrome is 1.5 times more likely to affect males than females.[2] Typically, spontaneous resolution occurs within 2-4 weeks of peak symptoms. If the paralysis continues to ascend toward the diaphragm, plasmapheresis or administration of intravenous immunoglobulins should be performed immediately. Both treatments are equally effective.


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