200 - A Rare Case of Miller-Fisher Guillain-Barre Syndrome

A 78-year-old male with hypertension, gastroesophageal reflux, alcohol use disorder, and chronic back pain presented to the emergency department from outpatient neurology clinic for progressive gait instability, bilateral leg weakness, headache, and dizziness for 3 weeks with headache for 1 week. He presented with unsteady, wide-based ataxic gait, positive Romberg test, and inability to fixate gaze on exam. 

On admission, he was found to be COVID-19 positive. MRI brain revealed no acute infarcts or hemorrhages. ESR, anti-dsDNA were sent to rule out autoimmune pathology; both were within normal limits. Lumbar puncture was subsequently done, revealing elevated cerebrospinal protein, but normal glucose levels, and white and red cell counts. Intravenous immunoglobulin was started for suspected Miller-Fisher Guillain-Barre Syndrome and stool campylobacter was sent, which was negative. After 3 days of treatment, the patient had resolution of gait instability and gaze fixation deficit. Physiatry evaluated the patient, and recommended outpatient physical therapy.

Discussions: Ataxic gait and lower extremity weakness may be concerning for more central neurologic causes, just as this case initially concerned outpatient neurology for viral cerebellitis or transverse myelitis. However, transient neurologic signs and symptoms combined with the elevated protein in the cerebrospinal fluid found on lumbar puncture after COVID diagnosis supported the diagnosis of Miller-Fisher Guillain-Barre Syndrome secondary to COVID. Resolution of symptoms after starting IVIG further validated this conclusion; PM&R and neurologic evaluation after treatment showed improvement in just 4 days. The headache was also likely related to COVID viral symptoms.

Conclusions: In patients with vague neurological symptoms but otherwise negative neurological workup, COVID testing may be considered to rule out COVID-related neurological complications such as Guillain-Barre Syndrome