Internal ophthalmoplegia as the initial symptom of Miller-Fisher syndrome.

Guillain-Barré syndrome (GBS) is an autoimmune polyradiculoneuropathy that may follow infection. The syndrome is divided into several subgroups: chronic inflammatory demyelinating polyneuropathy (the most frequent variant), acute pandysautonomia, acute motor axonal neuropathy, acute motor and sensory axonal neuropathy, and MillerFisher syndrome (MFS).1 This last syndrome, a rare variant of GBS, is characterised by the classic symptom triad of ophthalmoplegia, ataxia, and areflexia. In addition to this triad, bulbar paralysis, weakness, and sensory loss may also appear. We present the case of a patient with internal ophthalmoplegia as the initial symptom of MFS. Our patient is a 74-year-old woman with a history of primary hypothyroidism and long-term treatment with levothyroxine. She was referred to the emergency department by her primary care doctor due to moderate fronto-orbital headache and non-reactive mid-size pupils without loss of visual acuity. She presented no photophobia or sonophobia and had not been using eye drops. During the preceding week, the patient had experienced itching, mild pharyngeal pain, and self-limiting fever. She was treated with amoxicillin/clavulanic acid and anti-inflammatory drugs. During the neurological examination, the patient was conscious and oriented but showed non-reactive mid-sized pupils. Doctors observed no light-near dissociation, diplopia, nystagmus, abnormal eye movements, visual field deficits, abnormal cranial nerves, dysphagia, language and speech disorders, dysmetria, or motor or sensory disorders. Gait was normal and muscle stretch reflexes were rated 1/5. Romberg test was negative and there were no meningeal signs.