COVID-19-associated Miller-Fischer syndrome
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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
- MFS is a rare variant of Guillain-Barre syndrome, characterized by ophtalmoplegia, areflexia and ataxia.
Pathophysiology
- Miller Fisher Syndrome (MFS) is related to dysfunction of third, fourth, 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 ophthalmoparesis 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.[2]
Causes
- Although Miller Fisher Syndrome (MFS) has been detected in some patients with COVID-19, other viral and bacterial infections can also cause MFS:
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
- There are no established risk factors for MFS associated with COVID-19.
Screening
- There is insufficient evidence to recommend routine screening for patients with MFS caused by COVID-19.
Natural History, Complications, and Prognosis
- 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
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
- Less common symptoms of covid-19 associated with MFS include:
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
- Eye dropping
- Blurry vision
- Paresthesia
- Decreased sensation
- Myalgia
- Weakness of breathing muscle
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:
- Ganglioside (GM1) Antibodies, IgG and IgM
- GD1b Antibody, IgM
- GQ1b Antibody, IgG
Electrocardiogram
X-ray
- Chest X-ray is less sensitive in detection of COVID-19 in comparison with CT.
- However, in some cases lung consolidation and patchy peripheral opacities corresponding to ground glass opacities has been reported.[6]
Echocardiography or Ultrasound
- Lung ultrasound may be helpful in the evaluation of patients with COVID-19. It indicates :
- Multiple B-lines
- Ranging from focal to diffuse with spared areas
- Irregular and thickened pleural lines
- Subpleural consolidations
- Alveolar consolidations
- Bilateral A-lines
CT scan
The preliminary findings of CT in COVID-19 associated with MFS include:
- Bilateral ground glass opacities
- Air space consolidation
- Bronchovascular thickening
- Traction bronchiectasis
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
- 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).
- In some patients the combination of antiviral therapies like protease inhibitors, ritonavir, and lopinavir (100-400mg/day)[7] indicated partial success in treatment of COVID-19.
- Remdesivir (100-200mg/day)[8], a drug originally developed to treat Ebola virus, showed positive results against SARS-CoV-2.
- Dexamethasone (6mg/day)[9] has been announced as an effective treatment in patients with systematic manifestations.
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
- ↑ {{https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619}}
- ↑ {{https://pubmed.ncbi.nlm.nih.gov/10695710}}
- ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
- ↑ {{https://rarediseases.org/rare-diseases/miller-fisher-syndrome/}}
- ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
- ↑ {{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/}}
- ↑ 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.