An Overlapping Case of Miller Fisher Syndrome and Acute Motor Axonal Neuropathy in Children

Background: Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome (GBS), classically characterized by a triad consist of ophtalmoplegia, ataxia, and areflexia. It is an immune-mediated polyneuropathy which may be preceded by mild respiratory or gastrointestinal infection. The diagnosis is based on clinical patterns, cerebrospinal fluid (CFS) analysis, and nerve conduction studies. Some severe variant forms like limb weakness (overlapping GBS), lower cranial nerves involvement (bulbar palsy), or central nervous system involvement (Bickerstaff encephalitis) have been reported, which might need proper diagnosis and treatment. Case Presentation: A 6 years old boy presented with drooping of the upper eyelid, imbalance and tendency to fall on either side while walking. The past medical history showed upper respiratory tract infection 1 week earlier. Physical examination showed complete ophthalmoplegia, ataxia, and lost of deep tendon reflex. The patient later developed mild lower limb weakness, difficulty in swallowing and bilateral facial nerve palsy. Cerebrospinal fluid analysis showed albuminocytologic dissociation and nerve conduction studies showed mix type lesion (axonal and demyelination), predominantly motor axonal lesion which support AMAN variant of GBS. Intravenous immunoglobulin (IVIG) was given and the symptoms gradually improved. The patient was discharged from hospital after 3 weeks with mild ophthalmoplegia and completely recovered after 6 weeks. Conclusion: We have reported an overlapping case of Miller Fisher syndrome and AMAN in 6 years old boy. Intravenous immunoglobulin therapy gave a good outcome in this case. Keywords: miller fisher syndrome, guillain barre syndrome, acute motor axonal neuropathy, ophtalmoplegia, ataxia