To describe a rare clinical presentation of Miller Fischer Syndrome

Miller Fischer syndrome is a variant of Guillain- Barré syndrome characterized by Ophthalmoplegia with ataxia and areflexia. Nasal speech due to Palatal paralysis is a rare manifestation which has been rarely reported

55-year-old Male with history of Hypertension presented with acute change in voice and paresthesia. On the third day, patient started having double vision and gait instability. On exam, patient had bilateral ptosis, dysarthria, hyper nasal speech, bilateral glove and stocking type paresthesia with no loss of strength, diffuse areflexia and ataxia. MRI of spine did not reveal any peripheral nerve root enhancement. CSF studies showed normal cell count and protein levels. EMG/NCS revealed bilateral mild to moderate ulnar and median neuropathy, normal on Lower extremities. He was also monitored for respiratory compromise. Labs for autoimmune antibodies were sent including Myasthenia antibodies, GM1 and GD1B which were all negative, However GQ1b antibody returned positive with a titer of 1:6400

Patient was started on IVIg with the assumption of Guillain Barré syndrome variant based on clinical exam , even though other investigations including CSF analysis and EMG/Nerve conduction study were not supportive of the diagnosis. He subsequently improved over the next 2 weeks and was discharged home

Early recognition of various clinical presentations of Miller Fischer syndrome is critical for prompt treatment as respiratory failure due to cranial nerve palsies can be life threatening