707 - Miller Fisher Variant of Guillain-Barré Presenting After Traumatic Brain Injury

52 yo man with no medical history presented with loss of consciousness after falling 20+ feet from a utility pole. Imaging was notable for bilateral subdural and subarachnoid hemorrhages, multiple skull and bone fractures, and internal carotid artery injury. Hospital course was complicated by right facial paralysis and weakness. Imaging was negative for a new infarct. 

Symptoms were initially attributed to Bell's Palsy and steroids were started.  The patient's right facial paralysis resolved however he developed new onset left sided facial paralysis and areflexia.  MRI was negative for acute changes.  CSF studies were notable for albuminocytologic  dissociation consistent with Guillain-Barre syndrome.  Given the presence of multiple cranial neuropathies, areflexia, and other neurological symptoms, the patient was diagnosed with Miller Fisher syndrome.  He received 5 days of PLEX and was transferred to IRF. Rehabilitation course was complicated by agitation, vestibular dysfunction, and visual deficits. Medical management was initiated for symptom management.

 

Discussions: Guillain-Barré Syndrome (GBS) is a rare acute autoimmune condition in which the immune system attacks peripheral nerves. Miller Fisher (MF) variant is a rare subtype of GBS, with an incidence of 1-2 in 1,000,000,  that presents with areflexia, ophthalmoplegia and ataxia. MF usually affects the facial nerves, most often cranial nerves 3, 4 and 6. GQ1b ganglioside antibodies are a common serological finding and were found in this patient. While most cases are preceded by a viral infection, this patient did not have any infectious signs  prior to symptom development. Shedding light on unique sequela post TBI is important in tailoring patients’ rehabilitation needs.

Conclusions: We describe a unique case of Miller Fisher Syndrome that presented after traumatic brain injury. Recognizing this complication is important for clinicians in patient management