MILLER FISHER SYNDROME Mounika Lakhmalla, Arline Ficarra, Ethan Greenblatt, Gerard J. Dynes; Baton Rouge General Hospital, Baton Rouge, LA.
Introduction: Guillain-Barré syndrome (GBS) is a group of acute immune-mediated neuropathies usually preceded by an infectious illness. Miller- Fisher syndrome (MFS) is regarded as a rare variant of GBS and is found to affect 1 in every 1,000,000 healthy people, as well as 6.6% of all GBS patients. The characteristic triad includes ataxia, areflexia, and ophthalmoparesis. Case: A 43-year-old female without a past medical history presented 1-2 weeks after a gastrointestinal illness with complaints of diplopia and ataxia. The physical examination was remarkable for multi- directional nystagmus, bilateral lateral rectus gaze palsies, mild bilateral ptosis, hyporeflexia in knees, areflexia at the ankles, and absent distal vibratory sensation. After an extensive workup, the diagnosis of Miller-Fisher syndrome was
achieved based on clinical findings. Our patient was treated with intravenous immunoglobulin (IVIG), physical therapy, and supportive measures including gabapentin and methocarbamol. Her symptoms improved over 3 months. Discussion: Our case highlights the rare occurrence of Miller-Fisher syndrome that requires a high index of suspicion even with a negative IgG anti- GQ1b antibody in the serum. Diagnosis can be achieved considering the classic symptoms, CSF analysis with slightly elevated protein levels, and supported by nerve conduction studies. This case further emphasizes that early recognition of MFS symptoms is crucial, given the possibility of severe motor and sensory disabilities that could occur with delayed diagnosis and may seriously affect the quality of life of these patients.
MRSA BACTEREMIA LEADING TO ENDOGENOUS BACTERIAL ENDOPHTHALMITIS IN A 76-YEAR-OLD FEMALE WITH COMPLEX MEDICAL HISTORY Michelle Arsenault, Robert Weiss, Bhagya Challa, Katelyn Forest, Breanna Campbell; Baton Rouge General Hospital, Baton Rouge, LA.
Introduction: Endogenous bacterial endophthalmitis (EBE) is a rare but severe ocular infection that results from the hematogenous spread of bacteria. Case: A 76-year-old female with hypertension, coronary artery disease (status post coronary artery bypass grafting twice, chronic kidney disease stage III, atrial fibrillation, and mechanical mitral valve (on warfarin) presented with intermittent fever, chills, worsening fatigue, decreased appetite, and left eye pain. On admission, she was febrile with a max temperature of 102.6°F, heart rate of 100 bpm, and blood pressure of 138/49 mmHg. Initial lab work revealed a sodium level of 130 mmol/L, WBC count of 15.8 cells/mm3, and hemoglobin of 7.0 cells/mm3. She tested positive for influenza B. A chest X-ray showed vascular congestion, a left retrocardiac infiltrate, and bilateral pleural effusions, raising concerns for multifocal pneumonia and congestive heart failure
exacerbation. She was started on ceftriaxone and azithromycin for suspected pneumonia, but blood cultures subsequently grew methicillin-resistant Staphylococcus aureus (MRSA). Antibiotics were transitioned to vancomycin. The following day the patient was then complaining of blindness in her left eye and an ophthalmologic evaluation revealed endophthalmitis with hypopyon of the left eye. Intravitreal vancomycin was administered. A transesophageal echocardiogram (TEE) showed no vegetations but did reveal Lambl’s excrescences. Given her mechanical mitral valve, a prolonged course of antibiotics, akin to endocarditis treatment, was recommended. The patient was discharged on a 6-week course of vancomycin with outpatient follow-up, including repeat echocardiography to monitor for a progressive vegetation.
Discussion: This case demonstrates the
42
Made with FlippingBook Digital Publishing Software