An Approach to Acute Cranial Symptoms in Primary Care: Lesson From a Case of Miller Fisher Syndrome.
Humaira Jasme, Mimi Nashra Mohd Noh, Aiza Nur Izdihar Zainal-Abidin
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Case in brief
A 38-year-old woman developed acute diplopia, right eye pain, headache, and perioral numbness two weeks after an upper respiratory infection. Her initial neurological examination was unremarkable; brain CT and laboratory investigations were also unremarkable, and she was initially managed for migraine after referral to exclude ocular disease and posterior circulation stroke. Ophthalmology later identified ophthalmoplegia, followed by bulbar symptoms. Repeat neurological examination showed the classic triad of Miller Fisher syndrome: ophthalmoplegia, ataxia, and areflexia. After clinical deterioration, she received plasma exchange and gradually recovered; diplopia resolved by eight weeks after symptom onset.
What made this case unusual
The syndrome evolved from acute cranial symptoms with an initially normal neurological examination, and was first managed as migraine. Ophthalmoplegia and bulbar symptoms emerged later, making serial assessment important to recognition.
Diagnostic / clinical pearl
Miller Fisher syndrome may have subtle, evolving findings; a normal initial examination does not exclude it. Reassessment and timely specialist referral are important when acute cranial symptoms progress after a recent infection.