Acute ophthalmoplegia with pupillary areflexia associated with anti-GQ1b antibody

Characteristics of pupil palsy in miller-fisher syndrome: case reports and review of the literature

Pupil palsy has been a frequent finding in Miller Fisher syndrome (MFS), but its clinical characteristics have not been clearly defined. The basis for differential diagnosis with other diseases with pupil palsy has also remained vague. We report cases of four MFS patients with bilateral pupil palsy and specify pupil characteristics of light-near dissociation (LND), cholinergic super-sensitivity, vermiform movements, and prognosis. We conducted a literature review to compare with our cases and investigate common findings of pupil palsy in MFS patients. We suggest that the acute generalized pupil palsy without vermiform movements can serve as a key finding for the diagnosis of pupil palsy associated with MFS. However, the presence of LND and cholinergic super-sensitivity was not distinctive clinical findings in MFS patients who had pupil palsy and did not prove useful for differential diagnosis. The prognosis of pupil palsy in MFS patients was good in our 4 cases and the literature review.

Pupillary Involvement in Miller Fisher Syndrome

Miller Fisher Syndrome is characterised by the classical triad of ophthalmoplegia, ataxia, and areflexia. Ophthalmoparesis without ataxia, without areflexia, or with neither have been attributed as atypical forms of MFS. We report two patients with MFS who had tonic pupils and raised anti-GQ1b antibody titres. Bilateral dilated pupils (either tonic or fixed) can be a manifestation of MFS and anti-GQ1b immunoglobulin G (IgG) antibodies are useful to confirm the diagnosis in unexplained cases. The site of involvement is thought to be the ciliary ganglion or short ciliary nerves.

External and internal ophthalmoplegia, facial diplegia, ataxia and exaggerated deep tendon reflexes associated with anti-GQ1b antibodies: A new variant of acute ophthalmoparesis

We present the case report of a patient with antibodies to ganglioside GQ1b, who presented with pupillary areflexia, external ophthalmoplegia, ataxia, brisk deep tendon reflexes and facial muscle diplegia following a viral illness. The patient was diagnosed with acute ophthalmoparesis, which is a rare variant of Miller Fisher syndrome that has been characterised recently. We describe a unique presentation of this rare condition, and consider the range of presentations that can occur in association with antibodies to the GQ1b ganglioside.

Neuromuscular junction dysfunction in Miller Fisher syndrome

The Miller Fisher syndrome (MFS) is a variant of Guillain-Barre syndrome with the clinical triad of areflexia, ataxia, and ophthalmoparesis. The classic pathologic mechanism of disease is considered to be peripheral nerve demyelination. We present a patient with binocular diplopia and a diagnosis of myasthenia gravis from 15 years prior. Electrophysiologic studies revealed a decremental response on repetitive nerve stimulation, suggesting recurrent myasthenia. However, pupillary light-near dissociation and areflexia were present and positive anti-GQ1b antibodies confirmed MFS. This patient highlights a developing recognition of impaired neuromuscular transmission in MFS. His presentation is discussed in the context of the animal and human literature on neuromuscular junction abnormalities in MFS.

Clinical and immunological spectrum of the Miller Fisher syndrome

The Miller Fisher syndrome (MFS), characterized by ataxia, areflexia, and ophthalmoplegia, was first recognized as a distinct clinical entity in 1956. MFS is mostly an acute, self-limiting condition, but there is anecdotal evidence of benefit with immunotherapy. Pathological data remain scarce. MFS can be associated with infectious, autoimmune, and neoplastic disorders. Radiological findings have suggested both central and peripheral involvement. The anti-GQ1b IgG antibody titer is most commonly elevated in MFS, but may also be increased in Guillain-Barré syndrome (GBS) and Bickerstaff's brainstem encephalitis (BBE). Molecular mimicry, particularly in relation to antecedent Campylobacter jejuni and Hemophilus influenzae infections, is likely the predominant pathogenic mechanism, but the roles of other biological factors remain to be established. Recent studies have demonstrated the presence of neuromuscular transmission defects in association with anti-GQ1b IgG antibody, both in vitro and in vivo. Collective findings from clinical, radiological, immunological, and electrophysiological techniques have helped to define MFS, GBS, and BBE as major disorders within the proposed spectrum of anti-GQ1b IgG antibody syndrome.

Single-fiber electromyography shows terminal axon dysfunction in Miller Fisher syndrome: a case report

We studied a patient with ophthalmoparesis and pupillary areflexia 2 weeks after a viral syndrome. Miller Fisher syndrome was suspected but GQ1b antibodies were not detected. To define neuromuscular involvement we performed electrodiagnostic studies. Single-fiber electromyography (SFEMG) in the extensor digitorum communis (EDC) showed abnormal jitter and axonal blocking, suggesting terminal axon dysfunction. Subsequent GQ1b antibody titers were elevated to borderline levels. Clinical symptoms gradually resolved. SFEMG may help characterize neuropathies associated with antibodies to neuronal ganglioside and identify involvement of the terminal axon and neuromuscular junction.