COVID-19-associated Miller-Fischer syndrome: Difference between revisions

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{{SI}}
{{SI}}


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{Arash.M}}, {{Fs}}


{{SK}}  
{{SK}} MFS, fisher syndrome


==Overview==
==Overview==


'''Miller Fisher Syndrome (MFS)''' is an acute peripheral neuropathy which can develop after exposure to a viral or bacterial infection. It includes triad of '''ophtalmoplegia''', '''areflexia''' and '''ataxia'''. In '''covid-19''' pandemic period, while '''covid-19''' typically presents with fever, SOB and respiratory symptoms, '''MFS''' with prior history of '''covid-19''' has been seen in several cases all around the world.  
[[Miller Fisher Syndrome]] (MFS) is an acute [[peripheral neuropathy]] that can develop after exposure to a [[Virus|viral]] or [[bacterial]] infection. It includes triad of [[ophthalmoplegia]], [[areflexia]] and [[ataxia]]. In [[COVID-19]] pandemic period, while [[COVID-19]] typically presents with [[fever]], [[shortness of breath]] (SOB) and [[respiratory]] symptoms, MFS with prior history of [[COVID-19]] has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of [[COVID-19]] patients have reported peripheral [[neurological]] symptoms.
<br> One retrospective study in 214 patients has shown that 8.9 % of '''covid-19''' patients have reported peripheral neurological symptoms.


==Historical Perspective==
==Historical Perspective==


The first reported case of '''MFS''' with history of '''covid-19''' was detected on January 2020 in Shanghai, who was a middle-age woman diagnosed with '''MFS''' presented with areflexia, acute weakness in both legs and severe fatigue. Further reports were announced by medical groups in Spain and the USA which presented '''neuro-ophtalmological''' symptoms. <ref>{{Gutierrez-Ortiz C, Mendez A, Rodrigo-Rey S, et al. Miller Fisher syndrome and polyneuritis cranialis in COVID-19. Neurology 2020; April 17. doi: 10.1212/WNL.0000000000009619}} </ref>
* The first reported case of MFS with a history of [[COVID-19]] was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with [[areflexia]], acute [[weakness]] in both legs and severe [[fatigue]].
* Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. <ref><nowiki>{{</nowiki>https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619<nowiki>}}</nowiki></ref>


==Classification==
==Classification==


'''MFS''' is a rare variant of [[Guillain-Barre syndrome]], characterized by '''ophtalmoplegia''', '''areflexia''' and '''ataxia'''.
* MFS is a rare variant of [[Guillain-Barre syndrome]], characterized by [[ophtalmoplegia]], [[areflexia]] and [[ataxia]].


==Pathophysiology==
==Pathophysiology==


'''MFS''' is related to dysfunction of third, forth and sixth cranial nerves. A typical serological finding in patients with '''MFS''' and prior history of '''covid-19''' is antibodies against '''GQ1b ganglioside''', though negative test for antibodies does not rule out the diagnosis. The presence of ophtalmoparesis in '''MFS''' is related to a action of '''anti-GQ1b antibodies''' on the neuromuscular junction between the cranial nerves and ocular muscle. '''ELISA test''' is positive in 70% to 90% of patients.<ref>{{https://pubmed.ncbi.nlm.nih.gov/10695710}}</ref>
* [[Miller Fisher Syndrome]] (MFS) is related to dysfunction of third, fourth, and sixth [[cranial nerves]].  
* A typical [[Serology|serological]] finding in patients with MFS and prior history of [[covid-19]] is antibodies against GQ1b [[ganglioside]], though negative test for [[antibodies]] does not rule out the [[diagnosis]].  
* The presence of [[ophthalmoparesis]] in MFS is related to a action of anti-GQ1b [[antibodies]] on the [[neuromuscular junction]] between the [[cranial nerves]] and [[Ocular muscles|ocular muscle]]. [[ELISA test]] is positive in 70% to 90% of patients.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/10695710<nowiki>}}</nowiki></ref>


==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].


OR
* Although [[Miller Fisher Syndrome]] (MFS) has been detected in some patients with [[COVID-19]], other viral and [[bacterial]] infections can also cause MFS:
 
**[[Influenza Virus]]
Common causes of [disease] include [cause1], [cause2], and [cause3].
**[[Cytomegalovirus]]
 
**[[Zika virus]]
OR
**[[Mycoplasma]]
 
**[[Campylobacter]]
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
 
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].


==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
OR


[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
*For further information about the differential diagnosis, [[COVID-19-associated Miller-Fischer syndrome differential diagnosis|click here]].
* To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
OR


In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
* While the [[incidence]] of MFS is one or two-person per million each year, the [[prevalence]] of MFS associated with [[COVID-19]] is still unknown.
 
OR
 
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
 
 
 
Patients of all age groups may develop [disease name].
 
OR
 
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
 
OR
 
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
 
OR
 
[Chronic disease name] is usually first diagnosed among [age group].
 
OR
 
[Acute disease name] commonly affects [age group].
 
 
 
There is no racial predilection to [disease name].
 
OR
 
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
 
 
 
[Disease name] affects men and women equally.
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
 
 
The majority of [disease name] cases are reported in [geographical region].
 
OR
 
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
OR
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].


OR
* There are no established [[Risk factor|risk factors]] for MFS associated with [[COVID-19]].
 
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR


According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
* There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for patients with MFS caused by [[COVID-19]].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
OR


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
* There is an increased risk of death in patients over the age of 60-year-old. Hence, the [[mortality rate]] is estimated to be 3.6%.
* Risk factors for severe illness and poor [[prognosis]] include:
**[[Old age]]
** Male gender
** Patients with  
***[[Diabetes Mellitus]]
***[[Hypertension]]
***[[COPD]]
***[[CKD]]


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].


OR
* Although the diagnosis of [[COVID-19]] is based on [[respiratory]] symptoms, it can be associated with [[neurological]] symptoms, which overlap the diagnosis of MFS.
* Consequently, inpatient with prior history of [[COVID-19]], other [[Neurological|neurologic]] diseases should be ruled out and anti-GQ1b [[antibody]] test should be considered.
* Also, in new patients with suspicious symptoms for [[COVID-19]] and neurological symptoms, a nasal swab test and neurological examination should be considered.
* [[Magnetic resonance imaging|MRI]] may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>. <ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>


The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
===History and Symptoms===
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR


There are no established criteria for the diagnosis of [disease name].
==== Common symptoms ====


===History and Symptoms===
* Common [[symptoms]] of covid-19 associated with [[MFS]] include:
The majority of patients with [disease name] are asymptomatic.
** [[Shortness of breath]]
**[[Cough]]
**[[Fever]]
**[[Ophthalmoplegia]]
**[[Areflexia]]
**[[Ataxia]]


OR
==== Less common symptoms ====


The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
* Less common symptoms of covid-19 associated with [[MFS]] include:
** [[Headache]]<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>
**[[Diplopia]]
**[[Blurred vision]]
**[[Ptosis]]
**[[Facial droop]]


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].


OR
* Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
====Vitals====
Abnormal signs associated with covid-19:
* [[Tachycardia]]
* [[Tachypnea]]
*[[Fever]]


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
====Neurological====
 
* [[Eye dropping]]
OR
* [[Blurry vision]]
 
* [[Paresthesia]]
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
* Decreased sensation
* [[Myalgia]]
* Weakness of breathing muscle


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
OR
[Test] is usually normal among patients with [disease name].
OR
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
OR


There are no diagnostic laboratory findings associated with [disease name].
* Laboratory findings consistent with the diagnosis of COVID-19 include positive [[PCR]] nasal swab.
* Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:
**[[Ganglioside]] (GM1) [[Antibodies]], [[IgG]] and [[IgM]]
** GD1b [[Antibody]], [[IgM]]
** GQ1b Antibody, [[IgG]]


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
OR


An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19]].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].
OR


An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* [[Chest X-ray]] is less sensitive in detection of [[COVID-19]] in comparison with [[Computed tomography|CT]].  
 
* However, in some cases [[lung consolidation]] and patchy peripheral opacities corresponding to [[ground glass opacities]] has been reported.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/<nowiki>}}</nowiki></ref>
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
OR
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


OR
* Lung [[ultrasound]] may be helpful in the evaluation of patients with COVID-19. It indicates :


There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
* Multiple B-lines
** Ranging from focal to diffuse with spared areas
* Irregular and thickened [[pleural]] lines
* Subpleural consolidations
*[[Alveolar]] [[Consolidation (medicine)|consolidations]]
* Bilateral [[A-lines]]


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
The preliminary findings of [[Computed tomography|CT]] in COVID-19 associated with MFS include:
 
* Bilateral ground glass opacities
OR
* Air space [[Consolidation (medicine)|consolidation]]
 
* Bronchovascular thickening
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* Traction [[bronchiectasis]]
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].


OR
* Brain [[Magnetic resonance imaging|MRI]] may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and [[neurological]] manifestations.  
 
* Although there can be no abnormalities, multiple [[Cranial nerves|cranial nerve]] enhancement has been reported in some patients.
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
 
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
* There are no other diagnostic studies associated with COVID-19 with MFS manifestations.


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR


Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
* No specific treatment and vaccine exists for covid-19 yet.
 
* However, patients with moderate to severe [[ARDS]] and respiratory manifestations can benefit from [[Mechanical ventilation]] and [[extracorporeal membrane oxygenation]] (ECMO).  
OR
* In some patients the combination of antiviral therapies like [[protease inhibitors]], [[Ritonavir clinical pharmacology|ritonavir]], and [[lopinavir]] (100-400mg/day)<ref name="CaoWang2020">{{cite journal|last1=Cao|first1=Bin|last2=Wang|first2=Yeming|last3=Wen|first3=Danning|last4=Liu|first4=Wen|last5=Wang|first5=Jingli|last6=Fan|first6=Guohui|last7=Ruan|first7=Lianguo|last8=Song|first8=Bin|last9=Cai|first9=Yanping|last10=Wei|first10=Ming|last11=Li|first11=Xingwang|last12=Xia|first12=Jiaan|last13=Chen|first13=Nanshan|last14=Xiang|first14=Jie|last15=Yu|first15=Ting|last16=Bai|first16=Tao|last17=Xie|first17=Xuelei|last18=Zhang|first18=Li|last19=Li|first19=Caihong|last20=Yuan|first20=Ye|last21=Chen|first21=Hua|last22=Li|first22=Huadong|last23=Huang|first23=Hanping|last24=Tu|first24=Shengjing|last25=Gong|first25=Fengyun|last26=Liu|first26=Ying|last27=Wei|first27=Yuan|last28=Dong|first28=Chongya|last29=Zhou|first29=Fei|last30=Gu|first30=Xiaoying|last31=Xu|first31=Jiuyang|last32=Liu|first32=Zhibo|last33=Zhang|first33=Yi|last34=Li|first34=Hui|last35=Shang|first35=Lianhan|last36=Wang|first36=Ke|last37=Li|first37=Kunxia|last38=Zhou|first38=Xia|last39=Dong|first39=Xuan|last40=Qu|first40=Zhaohui|last41=Lu|first41=Sixia|last42=Hu|first42=Xujuan|last43=Ruan|first43=Shunan|last44=Luo|first44=Shanshan|last45=Wu|first45=Jing|last46=Peng|first46=Lu|last47=Cheng|first47=Fang|last48=Pan|first48=Lihong|last49=Zou|first49=Jun|last50=Jia|first50=Chunmin|last51=Wang|first51=Juan|last52=Liu|first52=Xia|last53=Wang|first53=Shuzhen|last54=Wu|first54=Xudong|last55=Ge|first55=Qin|last56=He|first56=Jing|last57=Zhan|first57=Haiyan|last58=Qiu|first58=Fang|last59=Guo|first59=Li|last60=Huang|first60=Chaolin|last61=Jaki|first61=Thomas|last62=Hayden|first62=Frederick G.|last63=Horby|first63=Peter W.|last64=Zhang|first64=Dingyu|last65=Wang|first65=Chen|title=A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19|journal=New England Journal of Medicine|volume=382|issue=19|year=2020|pages=1787–1799|issn=0028-4793|doi=10.1056/NEJMoa2001282}}</ref> indicated partial success in treatment of [[COVID-19]].
 
* [[Remdesivir]] (100-200mg/day)<ref name="urlCoronavirus disease 2019 (COVID-19) investigational drug information for remdesivir">{{cite web |url=https://reference.medscape.com/drug/remdesivir-4000090 |title=Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir |format= |work= |accessdate=}}</ref>, a drug originally developed to treat [[Ebola virus]], showed positive results against [[SARS-CoV-2]].
The majority of cases of [disease name] are self-limited and require only supportive care.
* [[Dexamethasone]] (6mg/day)<ref name="urlCorticosteroids | Coronavirus Disease COVID-19">{{cite web |url=https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/ |title=Corticosteroids &#124; Coronavirus Disease COVID-19 |format= |work= |accessdate=}}</ref> has been announced as an effective treatment in patients with systematic manifestations.
 
OR
 
[Disease name] is a medical emergency and requires prompt treatment.
 
OR
 
The mainstay of treatment for [disease name] is [therapy].
 
OR
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
OR
 
[Therapy] is recommended among all patients who develop [disease name].
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
OR
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
OR
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].


OR
* Surgical intervention is not recommended for the management of covid-19.
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
OR
There are no available vaccines against [disease name].
OR
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
OR
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
OR


Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
* Effective measures for the [[primary prevention]] of [[covid-19]] include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Latest revision as of 23:49, 12 December 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2], Fahimeh Shojaei, M.D.

Synonyms and keywords: MFS, fisher syndrome

Overview

Miller Fisher Syndrome (MFS) is an acute peripheral neuropathy that can develop after exposure to a viral or bacterial infection. It includes triad of ophthalmoplegia, areflexia and ataxia. In COVID-19 pandemic period, while COVID-19 typically presents with fever, shortness of breath (SOB) and respiratory symptoms, MFS with prior history of COVID-19 has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of COVID-19 patients have reported peripheral neurological symptoms.

Historical Perspective

  • The first reported case of MFS with a history of COVID-19 was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with areflexia, acute weakness in both legs and severe fatigue.
  • Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. [1]

Classification

Pathophysiology

Causes

Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • While the incidence of MFS is one or two-person per million each year, the prevalence of MFS associated with COVID-19 is still unknown.

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for patients with MFS caused by COVID-19.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • Although the diagnosis of COVID-19 is based on respiratory symptoms, it can be associated with neurological symptoms, which overlap the diagnosis of MFS.
  • Consequently, inpatient with prior history of COVID-19, other neurologic diseases should be ruled out and anti-GQ1b antibody test should be considered.
  • Also, in new patients with suspicious symptoms for COVID-19 and neurological symptoms, a nasal swab test and neurological examination should be considered.
  • MRI may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.[3]. [4]

History and Symptoms

Common symptoms

Less common symptoms

Physical Examination

  • Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:

Vitals

Abnormal signs associated with covid-19:

Neurological

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of COVID-19 include positive PCR nasal swab.
  • Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:

Electrocardiogram

X-ray

Echocardiography or Ultrasound

  • Lung ultrasound may be helpful in the evaluation of patients with COVID-19. It indicates :

CT scan

The preliminary findings of CT in COVID-19 associated with MFS include:

MRI

  • Brain MRI may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and neurological manifestations.
  • Although there can be no abnormalities, multiple cranial nerve enhancement has been reported in some patients.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with COVID-19 with MFS manifestations.

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of covid-19.

Primary Prevention

  • Effective measures for the primary prevention of covid-19 include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.

References

  1. ↑ {{https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619}}
  2. ↑ {{https://pubmed.ncbi.nlm.nih.gov/10695710}}
  3. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  4. ↑ {{https://rarediseases.org/rare-diseases/miller-fisher-syndrome/}}
  5. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  6. ↑ {{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/}}
  7. ↑ Cao, Bin; Wang, Yeming; Wen, Danning; Liu, Wen; Wang, Jingli; Fan, Guohui; Ruan, Lianguo; Song, Bin; Cai, Yanping; Wei, Ming; Li, Xingwang; Xia, Jiaan; Chen, Nanshan; Xiang, Jie; Yu, Ting; Bai, Tao; Xie, Xuelei; Zhang, Li; Li, Caihong; Yuan, Ye; Chen, Hua; Li, Huadong; Huang, Hanping; Tu, Shengjing; Gong, Fengyun; Liu, Ying; Wei, Yuan; Dong, Chongya; Zhou, Fei; Gu, Xiaoying; Xu, Jiuyang; Liu, Zhibo; Zhang, Yi; Li, Hui; Shang, Lianhan; Wang, Ke; Li, Kunxia; Zhou, Xia; Dong, Xuan; Qu, Zhaohui; Lu, Sixia; Hu, Xujuan; Ruan, Shunan; Luo, Shanshan; Wu, Jing; Peng, Lu; Cheng, Fang; Pan, Lihong; Zou, Jun; Jia, Chunmin; Wang, Juan; Liu, Xia; Wang, Shuzhen; Wu, Xudong; Ge, Qin; He, Jing; Zhan, Haiyan; Qiu, Fang; Guo, Li; Huang, Chaolin; Jaki, Thomas; Hayden, Frederick G.; Horby, Peter W.; Zhang, Dingyu; Wang, Chen (2020). "A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19". New England Journal of Medicine. 382 (19): 1787–1799. doi:10.1056/NEJMoa2001282. ISSN 0028-4793.
  8. ↑ "Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir".
  9. ↑ "Corticosteroids | Coronavirus Disease COVID-19".


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