Muhammad Awais, Ashraf H M, Muhammad Babar Khan.
Miller Fischer syndrome.
Pak Armed Forces Med J Jan ;55(4):366-8.

A 16 years old boy was brought with complaints of headache, dizziness, diplopia, and dysphagia for last one day. One week prior to these complaints, he had mild upper respiratory tract infection. On examination, he was an averagely built, young adult, fully conscious and oriented. His vital signs were normal with no bradycardia, orthostatic hypo tension or some other specific sign. His higher mental functions were intact. Pupils were normal in size and equally reactive to light. His speech was dysarthric with nasal twang. Cranial nerve examination revealed IIIrd, IVth and VIth nerve paralysis causing ophthalmoplegia and bilateral ptosis. There was bilateral facial weakness due to bilateral facial nerve palsy. There was IXth, Xth, and XIIth nerve palsies resulting in dysphagia, dysarthria and absence of gag reflex. There were no intention tremors, incoordination, dysdiadochokinesia or ataxia showing absence of cerebellar involvement. Grade of power was 5/5 in all four limbs. All superficial and deep reflexes were normal. Examination of throat, cardiovascular system, gastrointestinal tract and respiratory system didn`t reveal any abnormality. Examination of his Cerebrospinal fluid was done at the time of admission which was clear with normal pressure, protein (22 mg/ dl), glucose and cell count. His computerized axial topographic scan was urgently performed which showed normal intensity and came out to be normal. He was admitted to the intensive care unit to monitor his respiratory status. Stool and serum cultures were sent for botulinum toxin which resulted in negative. During next a few days, patient remained stable and was managed by supportive care. Repeat CSF examination was performed after five days which showed elevated level of proteins i.e., 474 mg/dl which was a real catch point and helped us in clinching the diagnosis. On the basis of clinical presentation of the patient and elevated protein levels in CSF, a provisional diagnosis of Miller Fischer Syndrome was made. Patient was managed according to the standard guidelines and he improved.

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