Age: 18.0
Sex: M
Vaccine: HEPAB, MNQ
Symptoms: Heterophoria, Hypotension, Immunoglobulin therapy, Miller Fisher syndrome, Muscle disorder
Clinical narrative: The pt received HepA/HepB, Meningococcal and Tdap on 9/9/10. He was in his normal state of good health at that time. On approximately 9/14/10 the pt noted cough, head congestion, body aches. On 9/20/10 he noted sore throat. The pt reported to medical on 9/28/10 with the above complaints plus nausea, vomiting, chills and feeling feverish. Additionally, he reported a 2 week history of intermittent headaches (which were mild to moderate [4/10] and improved with rest) after being hit in the head during pugil stick training. The pt denied loss of consciousness, blurred vision and dizziness. Despite symptomatic treatment, the patient's symptoms continued to worsen. He reported back to medical on 9/30/10 with additional complaints of fever (102.8), diarrhea, blurred vision (VA OU 20/50 vs 20/20 OU on 9/8/10), and a 20 minute episode of a yellowish tint to his vision. The pt was started on antibiotics and put on BR for 48 hours. On 10/2/10 the pt noted that his left eyelid was drooping and he had double vision and a sensation of pressure behind his left eye. The pt reported to medical and his exam revealed ptosis and an incomitant esotropia OS with pupillary asymmetry (OS>OD). The pt denied muscle weakness, numbness/tingling, gait instability, or difficulty breathing, swallowing, urinating or defecating. He was admitted to hospital. Labs revealed slightly elevated inflammatory markers (see below). CT was normal except for a finding of sinusitis and MRA was without acute findings (see below). The pt was diagnosed per Ophthalmology with sixth cranial nerve palsy secondary to idiopathic orbital pseudotumor and was started on Prednisone 80mg. Examination (including endoscopic examination) by ENT did not find the sinusitis to be a contributing factor for the pt's symptoms. The pt was transferred to hospital on 10/9/10 with continued complaints of diplopia worse with distance and affecting both near and distant VA. On 10/14/10 the pt began to experience moderate/severe (7/10) LBP when he moved from a lying to a standing or sitting position which typically lasted about 5 minutes and resolved without treatment. This episodic LBP related to positional change continued for about 2 weeks. The pt had an EMG/NCS on 10/21/10 which concluded "small elevation in jitter in the left frontalis and orbicularis oculi muscle that could suggest a defect in neuromuscular transmission" (see below). After 4 weeks of steroid therapy with no objective improvement in the pt's ocular symptoms and the pt's progressive GI distress it was decided to taper the pt off the steroids. On 11/8/10 anti-GQ1b antibodies returned which were positive and the pt was diagnosed with GUILLAIN-BARRE Syndrome, Miller Fisher variant. The hospital was consulted regarding the potential treatment with IVIG. After risk/benefit analysis is was decided to proceed, but the pt began to show improvement of his diplopia so the IVIG therapy was withheld. The pt was transferred to the Active Duty Rehab Unit on 11/18/10 for vision rehab. The pt was discharged on 2/111/11. He denied ocular pressure/pain; his visual acuity is 20/20 OU (distant and near) Abnormal high esophoria was noted on exam. He continues with diplopia although improved.