Case Presentation: We present the case of a physically active 41-year-old male with a history of anxiety and restless leg syndrome who presented to the emergency department with complaints of vertigo, left arm numbness, and voice changes that progressed over less than two days. Initial concerns for an acute ischemic stroke prompted a stroke code, with the patient’s National Institutes of Health Stroke Scale (NIHSS) score recorded as 4. Neurological consultation recommended a CT and MRI, but no acute intracranial pathology was identified. The patient was admitted to the hospital internal medicine team for observation under the diagnosis of “MRI-negative stroke.”Upon admission, the patient’s neurological condition rapidly deteriorated over approximately 3 to 5 hours, with the development of breathing difficulty, bilateral leg weakness, ophthalmoplegia, and bulbar symptoms, including nasal and slurred speech, alongside persistent left arm weakness. The primary team raised suspicion of the Miller Fisher variant of Guillain-Barré Syndrome (GBS), which was confirmed through neurological consultation and a positive anti-GQ1b antibody in the cerebrospinal fluid (CSF), despite the absence of albumino-cytologic dissociation typically seen in GBS.The patient was transferred to the Medical Intensive Care Unit (MICU) due to worsening respiratory function, and plasmapheresis (PLEX) was initiated. Following five PLEX sessions over 10 days, the patient showed significant improvement, with near-complete recovery at discharge.
Discussion: This case highlights the importance of considering GBS in the differential diagnosis of rapidly progressing neurological deficits, even in the context of negative initial imaging for stroke and unexpected rapid progression of symptoms The absence of classic CSF findings should not delay treatment. Early recognition and treatment of GBS are critical to improving patient outcomes, especially in the setting of rapid progression and potential respiratory compromise.
Conclusions: Clinicians should maintain a high index of suspicion for GBS in patients with atypical presentations and negative imaging studies for stroke. This case emphasizes the importance of serial clinical evaluations and multidisciplinary collaboration to ensure timely diagnosis and intervention, preventing potential morbidity and mortality associated with GBS. Further studies are required to highlight in-hospital outcomes, appropriate resource utilization, and guideline development on the sequence of care escalation.