J Korean Ophthalmol Soc.  2009 Apr;50(4):645-648. 10.3341/jkos.2009.50.4.645.

A Case of Anti-GQ1b-Positive Atypical Miller Fisher Syndrome With Pupil Involvement

• Ahn JH
• Lee SG

• KMID: 2212270
• DOI: http://doi.org/10.3341/jkos.2009.50.4.645

Abstract

PURPOSE: To report a case of atypical Miller Fisher syndrome with pupil involvement.
CASE SUMMARY
An 18-year-old woman visited our clinic with a headache and blurred vision. Ophthalmic examination revealed a corrected visual acuity of 20/20 in both eyes, with both pupils dilated to 7.5 mm. There was a loss of light reflex and near reflex in both eyes. Ocular motor examination revealed bilateral abduction, and supraduction limitation, and mild adduction limitation. Neurological examination demonstrated hyporeflexia without ataxia. Brain CT, brain MRI, nerve conduction test, CSF study, and thyroid function tests were normal. The serologic anti-GQ1b IgG test was positive.
CONCLUSIONS
We confirmed a case of atypical Miller Fisher syndrome with an anti-GQ1 antibody test that had pupil involvement, areflexia, and acute ophthlamoparesis.

Keyword

Anti GQ1b IgG antibody; Miller-Fisher syndrome; Pupil

MeSH Terms

Adolescent
Ataxia
Brain
Eye
Female
Headache
Humans
Immunoglobulin G
Light
Miller Fisher Syndrome
Neural Conduction
Neurologic Examination
Pupil
Reflex
Reflex, Abnormal
Thyroid Function Tests
Vision, Ocular
Visual Acuity
Immunoglobulin G

Figure

• 

  Figure 1. On the 3rd day of hospitalization, both pupils were dilated and ocular motor examination revealed bilateral complete limitation of abduction and supraduction and mild limitation of adduction.

• 

  Figure 2. Eight weeks after the onset of symptoms, pupil diameters reduced to 4 mm, and oculomotor examination revealed only mild bilateral limitation of abduction.

Reference

References

1. Fisher M. An unusual variant of acute idiopathic polyneuritis (syndrome of ophthalmoplegia, ataxia and areflexia). N Engl J Med. 1956; 255:57–65.

2. Chiba A, Kusunoki S, Obata H, et al. Serum anti-GQ1b IgG antibody is associated with ophthalmoplegia in Miller Fisher syndrome and Guillain-Barre syndrome: clinical and immunohistochemical studies. Neurology. 1993; 43:1911–7.

3. Yuki N, Odaka M, Hirata K. Acute ophthalmoparesis (without ataxia) asociated with anti-GQ1b IgG antibody. Ophthalmology. 2001; 108:196–200.

4. Hwang YM, Choi IS, Kim KH. A Case of Miller Fisher Syndrome (Variant of Guillain Barre Syndrome-Ophthalmoplegia, Ataxia, Areflexia). J Korean Neurol Assoc. 1983; 2:85–8.

5. Jung SD, Kho KO, Lee KS, Jung YH. A Case of Miller Fisher Syndrome. J Korean Child Neurol Soc. 1993; 1:158–64.

6. Son MG, Ahn HS. Miller Fisher Syndrome. J Korean Ophthalmol Soc. 1997; 38:1470–9.

7. Kim BL, Kim JJ, Son MA, Lee HB. Occurrence of Miller Fisher syndrome after insect bite. J Korean Ophthalmol Soc. 1996; 37:1771–5.

8. Sohn HJ, Lee JH, Paik HJ, et al. A Case of atypical Miller Fisher Syndrome. J Korean Ophthalmol Soc. 2007; 48:878–82.

9. Berlit P, Rakicky J. The Miller Fisher syndrome. Review of the literature. J Clin Neuroophthalmol. 1992; 12:57–63.

10. Pinchoff BS, Slavin MI, Rosenstein D, Hyman R. Divergence paralysis as the initial sign in the Miller Fisher syndrome. Am J Ophthalmol. 1986; 101:741–2.

11. al-Din SN, Anderson M, Eeg-Olofsson O, Trontelj JV. Neuro-ophthalmic manifestations of the syndrome of ophthalmoplegia, ataxia and areflexia: a review. Acta Neurol Scand. 1994; 89:157–63.

12. Caccavale A, Mignemi L. Acute onset of a bilateral areflexical mydriasis in Miller Fisher syndrome: a rare neuro-ophthalmologic disease. J Neuroophthalmol. 2000; 20:61–2.

13. Chan YC, Wilder-Smith E, Chee MW. Acute ophthalmoplegia with pupillary areflexia associated with anti-GQ1b antibody. J Clin Neurosci. 2004; 11:658–60.

14. LO YL. Clinical and immunological spectrum of the miller fisher syndrome. Muscle Nerve. 2007; 36:615–27.

15. Jorgensen L, Vedeler CA. Miller-Fisher syndrome. Tidsskr Nor Laegeforen. 2005; 125:1327–8.

16. Odaka M, Yuki N, Hirata K. Anti-GQ1b IgG antibody syndrome: clinical and immunological range. J Neurol Neurosurg Psychiatry. 2001; 70:50–5.

17. Odaka M, Yuki N, Yamada M, et al. Bickerstaff's brainstem encephalitis: clinical features of 62 cases and a subgroup associated with Guillain–Barré syndrome. Brain. 2003; 126:2279–90.

18. Carpo M, Pedotti R, Allaria S, et al. Clinical presentation and outcome of Guillain-Barre and related syndromes in relation to anti-ganglioside antibodies. J Neurol Sci. 1999; 168:78–84.

19. Chiba A, Kusunoki S, Obata H, et al. Ganglioside composition of the human cranial nerves, with special reference to pathophysiology of Miller Fisher syndrome. Brain Res. 1997; 745:32–6.

20. Ohtsuka K, Nakamura Y, Tagawa Y, Yuki N. Immunoad-sorption therapy for Fisher syndrome associated with IgG anti-GQ1b antibody. Am J Ophthalmol. 1998; 125:403–6.

21. Yeh JH, Chen WH, Chen JR, Chiu HC. Miller Fisher syndrome with central involvement: successful treatment with plasmapheresis. Ther Apher. 1999; 3:69–71.