Title

Miller Fisher syndrome after COVID-19 vaccination: Case report and review of literature

Authors

Muhammad Sohaib Asghar (1), MBBS; Bhawna Randhi (1), MBBS; Praveen Gowtham Varma Dasaraju (1), MBBS; Rizwan Siddiqi (2), MBBS; Tehrim Khan (2), MBBS; Muhammad Junaid Tahir (3), MBBS; Md Saiful Islam (4,5), BPH; Nisar Ahmed (6), MBBS; Zohaib Yousaf (7), MBBS, MD, MSc, FACP; Gibran Ali (8), PhD. Affiliations: (1). Division of Nephrology and Hypertension, Mayo Clinic Rochester, MN, USA. (2). Wah Medical College, Affiliated with University of Health Sciences, Wah, Pakistan. (3). Lahore General Hospital, Lahore, Pakistan. (4). Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka-1342, Bangladesh. (5). Centre for Advanced Research Excellence in Public Health, Savar, Dhaka-1342, Bangladesh. (6). Texas Tech University Health Sciences Center, Lubbock, TX, USA. (7). Department of Internal Medicine, Reading Hospital Tower Health, Reading, PA, USA. (8). Department of Pulmonology and Critical Care, Mayo Clinic Rochester, MN, USA.

Introduction

Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome, classically diagnosed based on the clinical triad of ataxia, areflexia, and ophthalmoplegia. MFS is usually preceded by viral infections and febrile illness; however, only a few cases have been reported after vaccinations. MFS is a rare adverse effect after COVID-19 vaccination, and appropriate surveillance is required for early diagnosis and treatment. More than 9 billion COVID-19 vaccines have been administered worldwide and determining the causal relationship in every case of a potential adverse effect becomes challenging. Additional research is required to substantiate a temporal association between COVID-19 vaccination and MFS, and to further understand the pathophysiology behind such neurological complications, which would be vital in improving the safety of COVID-19 vaccines in the future.

Case Presentation

A 53-year-old hypertensive male presented with a 2-day history of progressive ascending paralysis of the lower limbs along with diplopia and ataxia, 8 days after the first dose of the Sinovac-Coronavac coronavirus disease 2019 (COVID-19) vaccination, with no prior history of any predisposing infections or triggers. Physical examination showed moderate motor and sensory loss with areflexia in the lower limbs bilaterally. Routine blood investigations and radiological investigations were unremarkable. Cerebrospinal fluid analysis showed albuminocytologic dissociation and nerve conduction studies revealed prolonged latencies with reduced conduction velocities. The diagnosis of MFS was established based on the findings of physical examination, cerebrospinal fluid analysis, and nerve conduction studies. A management plan was devised based on intravenous immunoglobulins, pregabalin, and physiotherapy. However, due to certain socioeconomic factors, the patient was managed conservatively with regular physiotherapy sessions. Follow-up after 6 weeks showed remarkable improvement, with complete resolution of symptoms 10 weeks after the discharge.

Discussion

This case suggests that MFS is a rare adverse effect after COVID-19 vaccination and additional research is required to substantiate a temporal association. Further studies are needed to understand the pathophysiology behind such complications to enhance the safety of COVID-19 vaccinations in the future. Our case shows numerous similarities to other cases and, in addition, exhibits the classical triad of MFS along with characteristic CSF results of albuminocytological dissociation and typical electromyography findings, depicting a common pathogenic mechanism and a consistent disease course. Previously, Zika virus outbreaks were also reported to be associated with GBS, with different prognoses and high mortality. Our case describes a patient with MFS caused due to the Sinovac–Coronavac vaccination in the absence of any other identifiable triggers. Although GBS cases have been reported after influenza, measles, and meningococcal vaccines, the incidence of postvaccination GBS and its variants is infrequent, with less than one case of GBS per million immunized persons. A literature search performed on PubMed on 03 December 2021 using Boolean operator strategy with keywords “(Miller Fisher syndrome OR MFS) AND (COVID-19 OR SARS-CoV-2) AND (vaccination)” showed 8 results. The screening of abstracts revealed 4 cases reporting MFS after COVID-19 vaccination. To the best of our knowledge, this is the first reported case of MFS associated with inactivated COVID-19 vaccine, and 5th overall case at the time of reporting.

References

[1]. Michaelson NM, Lam T, Malhotra A, Schiff ND, MacGowan DJL. Miller Fisher syndrome presenting after a second dose of Pfizer-BioNTech vaccination in a patient with resolved COVID-19: a case report. J Clin Neuromuscul Dis 2021;23:113–5. [2]. Abicic A, Adamec I, Habek M. Miller Fisher syndrome following Pfizer COVID-19 vaccine [published online ahead of print, 2021 Nov 24]. Neurol Sci 2021;01–3. doi:10.1007/s10072-021-05776-0. [3]. Nishiguchi Y, Matsuyama H, Maeda K, Shindo A, Tomimoto H. Miller Fisher syndrome following BNT162b2 mRNA coronavirus 2019 vaccination. BMC Neurol 2021;21:452. [4]. Dang YL, Bryson A. Miller-Fisher syndrome and Guillain-Barre syndrome overlap syndrome in a patient post Oxford-AstraZeneca SARS-CoV-2 vaccination. BMJ Case Rep 2021;14:e246701.