Case Presentation: A 63-year-old male with past medical history of hyperlipidemia and diabetes mellitus presented to an outside hospital with diplopia and new onset weakness, paresthesia, and numbness in bilateral lower extremities three days following a mild viral infection. The patient was discharged after two days without acute intervention following extensive negative workup including imaging, syphilis, vitamin B12 deficiency, thyroid abnormalities, acetylcholine receptor abnormalities, stroke/atherosclerosis, and acute demyelination. Four days later, he presented to us with worsening leg weakness and a reported fall, recent urinary incontinence, and new onset weakness with decreased sensation in bilateral hands. Physical exam was significant for diminished to absent patellar and Achilles reflexes bilaterally and mild left fourth cranial nerve palsy. Additional workup included lumbar puncture with protein 257 mg/dL, lymphocytes 100%, and glucose 66 mg/dL. Ascending paralysis, diplopia, and areflexia led to a clinical diagnosis of GBS, specifically MFS variant due to cranial nerve involvement. The patient was treated with plasmapheresis and discharged to an inpatient rehab facility due to deconditioning nine days later with improving symptoms.

Discussion: Guillain Barré Syndrome (GBS) is a rare post-infectious neuromuscular paralysis of the parasympathetic nervous system. Infection classically presents as an ascending, flaccid weakness alongside sensory deficits. However, there are reports of rare variants of GBS that alter the modalities of the eyes and even gait. Here we presented a rare case of a variant of GBS: Miller Fisher Syndrome (MFS). While the worldwide incidence of GBS is 1 in 100,000, the MFS variant represents a rare incidence of approximately 1 in 1,000,000. GBS-MFS is characterized by ophthalmoplegia, areflexia, and ataxia, all were present in this patient. While IVIG was initially administered, plasmapheresis was required due to advanced case presentation. This represents a classic case of MFS variant. Early recognition is critical for initiating prompt treatment and preventing long-lasting effects.

Conclusions: MFS is a rare variant of GBS that affects the eyes and gait of a patient. Classical symptom triad in patient is ataxia, areflexia, and opthalmoplegia. It is a clinical diagnosis – early recognition and ruling out of alternative diagnoses is critical. Late recognition may lead to extensive patient deconditioning, prolonged recovery, and more invasive treatment options.