COVID-19-associated Miller-Fischer syndrome: Difference between revisions

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{{SI}}
{{SI}}


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{Arash.M}}, {{Fs}}


{{SK}}  
{{SK}} MFS, fisher syndrome


==Overview==
==Overview==


'''Miller Fisher Syndrome (MFS)''' is an acute peripheral neuropathy which can develop after exposure to a viral or bacterial infection. It includes triad of '''ophtalmoplegia''', '''areflexia''' and '''ataxia'''. In '''covid-19''' pandemic period, while '''covid-19''' typically presents with fever, SOB and respiratory symptoms, '''MFS''' with prior history of '''covid-19''' has been seen in several cases all around the world.  
[[Miller Fisher Syndrome]] (MFS) is an acute [[peripheral neuropathy]] that can develop after exposure to a [[Virus|viral]] or [[bacterial]] infection. It includes triad of [[ophthalmoplegia]], [[areflexia]] and [[ataxia]]. In [[COVID-19]] pandemic period, while [[COVID-19]] typically presents with [[fever]], [[shortness of breath]] (SOB) and [[respiratory]] symptoms, MFS with prior history of [[COVID-19]] has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of [[COVID-19]] patients have reported peripheral [[neurological]] symptoms.
<br> One retrospective study in 214 patients has shown that 8.9 % of '''covid-19''' patients have reported peripheral neurological symptoms.


==Historical Perspective==
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].


The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
* The first reported case of MFS with a history of [[COVID-19]] was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with [[areflexia]], acute [[weakness]] in both legs and severe [[fatigue]].
 
* Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. <ref><nowiki>{{</nowiki>https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619<nowiki>}}</nowiki></ref>
In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
 
In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
 
There have been several outbreaks of [disease name], including -----.
 
In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].


==Classification==
==Classification==
There is no established system for the classification of [disease name].
OR
[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
OR
[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
OR
Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.


OR
* MFS is a rare variant of [[Guillain-Barre syndrome]], characterized by [[ophtalmoplegia]], [[areflexia]] and [[ataxia]].
 
If the staging system involves specific and characteristic findings and features:
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
 
OR
 
The staging of [malignancy name] is based on the [staging system].
 
OR
 
There is no established system for the staging of [malignancy name].


==Pathophysiology==
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
OR
It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
OR
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
OR
Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
OR
[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
OR
The progression to [disease name] usually involves the [molecular pathway].
OR


The pathophysiology of [disease/malignancy] depends on the histological subtype.
* [[Miller Fisher Syndrome]] (MFS) is related to dysfunction of third, fourth, and sixth [[cranial nerves]].
* A typical [[Serology|serological]] finding in patients with MFS and prior history of [[covid-19]] is antibodies against GQ1b [[ganglioside]], though negative test for [[antibodies]] does not rule out the [[diagnosis]].
* The presence of [[ophthalmoparesis]] in MFS is related to a action of anti-GQ1b [[antibodies]] on the [[neuromuscular junction]] between the [[cranial nerves]] and [[Ocular muscles|ocular muscle]]. [[ELISA test]] is positive in 70% to 90% of patients.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/10695710<nowiki>}}</nowiki></ref>


==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
OR


Common causes of [disease] include [cause1], [cause2], and [cause3].
* Although [[Miller Fisher Syndrome]] (MFS) has been detected in some patients with [[COVID-19]], other viral and [[bacterial]] infections can also cause MFS:
 
**[[Influenza Virus]]
OR
**[[Cytomegalovirus]]
 
**[[Zika virus]]
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
**[[Mycoplasma]]
 
**[[Campylobacter]]
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].


==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].


OR
*For further information about the differential diagnosis, [[COVID-19-associated Miller-Fischer syndrome differential diagnosis|click here]].
 
* To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
OR
In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.


OR
* While the [[incidence]] of MFS is one or two-person per million each year, the [[prevalence]] of MFS associated with [[COVID-19]] is still unknown.
 
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
 
 
 
Patients of all age groups may develop [disease name].
 
OR
 
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
 
OR
 
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
 
OR
 
[Chronic disease name] is usually first diagnosed among [age group].
 
OR
 
[Acute disease name] commonly affects [age group].
 
 
 
There is no racial predilection to [disease name].
 
OR
 
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
 
 
 
[Disease name] affects men and women equally.
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
 
 
The majority of [disease name] cases are reported in [geographical region].
 
OR
 
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].


OR
* There are no established [[Risk factor|risk factors]] for MFS associated with [[COVID-19]].
 
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR


According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
* There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for patients with MFS caused by [[COVID-19]].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].


OR
* There is an increased risk of death in patients over the age of 60-year-old. Hence, the [[mortality rate]] is estimated to be 3.6%.
 
* Risk factors for severe illness and poor [[prognosis]] include:
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
**[[Old age]]
 
** Male gender
OR
** Patients with
 
***[[Diabetes Mellitus]]
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
***[[Hypertension]]
***[[COPD]]
***[[CKD]]


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].


OR
* Although the diagnosis of [[COVID-19]] is based on [[respiratory]] symptoms, it can be associated with [[neurological]] symptoms, which overlap the diagnosis of MFS.
* Consequently, inpatient with prior history of [[COVID-19]], other [[Neurological|neurologic]] diseases should be ruled out and anti-GQ1b [[antibody]] test should be considered.
* Also, in new patients with suspicious symptoms for [[COVID-19]] and neurological symptoms, a nasal swab test and neurological examination should be considered.
* [[Magnetic resonance imaging|MRI]] may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>. <ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>


The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
===History and Symptoms===


OR
==== Common symptoms ====


The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
* Common [[symptoms]] of covid-19 associated with [[MFS]] include:
** [[Shortness of breath]]
**[[Cough]]
**[[Fever]]
**[[Ophthalmoplegia]]
**[[Areflexia]]
**[[Ataxia]]


OR
==== Less common symptoms ====


There are no established criteria for the diagnosis of [disease name].
* Less common symptoms of covid-19 associated with [[MFS]] include:
 
** [[Headache]]<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>
===History and Symptoms===
**[[Diplopia]]
The majority of patients with [disease name] are asymptomatic.
**[[Blurred vision]]
 
**[[Ptosis]]
OR
**[[Facial droop]]
 
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
* Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
====Vitals====
Abnormal signs associated with covid-19:
* [[Tachycardia]]
* [[Tachypnea]]
*[[Fever]]


OR
====Neurological====
 
* [[Eye dropping]]
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
* [[Blurry vision]]
* [[Paresthesia]]
* Decreased sensation
* [[Myalgia]]
* Weakness of breathing muscle


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].


OR
* Laboratory findings consistent with the diagnosis of COVID-19 include positive [[PCR]] nasal swab.
 
* Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
**[[Ganglioside]] (GM1) [[Antibodies]], [[IgG]] and [[IgM]]
 
** GD1b [[Antibody]], [[IgM]]
OR
** GQ1b Antibody, [[IgG]]
 
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR
 
There are no diagnostic laboratory findings associated with [disease name].


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].


OR
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19]].
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].


OR
* [[Chest X-ray]] is less sensitive in detection of [[COVID-19]] in comparison with [[Computed tomography|CT]].  
 
* However, in some cases [[lung consolidation]] and patchy peripheral opacities corresponding to [[ground glass opacities]] has been reported.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/<nowiki>}}</nowiki></ref>
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].


OR
* Lung [[ultrasound]] may be helpful in the evaluation of patients with COVID-19. It indicates :


Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* Multiple B-lines
 
** Ranging from focal to diffuse with spared areas
OR
* Irregular and thickened [[pleural]] lines
 
* Subpleural consolidations
There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
*[[Alveolar]] [[Consolidation (medicine)|consolidations]]
* Bilateral [[A-lines]]


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
The preliminary findings of [[Computed tomography|CT]] in COVID-19 associated with MFS include:
 
* Bilateral ground glass opacities
OR
* Air space [[Consolidation (medicine)|consolidation]]
 
* Bronchovascular thickening
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* Traction [[bronchiectasis]]
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
OR


[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* Brain [[Magnetic resonance imaging|MRI]] may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and [[neurological]] manifestations.
* Although there can be no abnormalities, multiple [[Cranial nerves|cranial nerve]] enhancement has been reported in some patients.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


OR
* There are no other diagnostic studies associated with COVID-19 with MFS manifestations.
 
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].


OR
* No specific treatment and vaccine exists for covid-19 yet.
* However, patients with moderate to severe [[ARDS]] and respiratory manifestations can benefit from [[Mechanical ventilation]] and [[extracorporeal membrane oxygenation]] (ECMO).  
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
* In some patients the combination of antiviral therapies like [[protease inhibitors]], [[Ritonavir clinical pharmacology|ritonavir]], and [[lopinavir]] (100-400mg/day)<ref name="CaoWang2020">{{cite journal|last1=Cao|first1=Bin|last2=Wang|first2=Yeming|last3=Wen|first3=Danning|last4=Liu|first4=Wen|last5=Wang|first5=Jingli|last6=Fan|first6=Guohui|last7=Ruan|first7=Lianguo|last8=Song|first8=Bin|last9=Cai|first9=Yanping|last10=Wei|first10=Ming|last11=Li|first11=Xingwang|last12=Xia|first12=Jiaan|last13=Chen|first13=Nanshan|last14=Xiang|first14=Jie|last15=Yu|first15=Ting|last16=Bai|first16=Tao|last17=Xie|first17=Xuelei|last18=Zhang|first18=Li|last19=Li|first19=Caihong|last20=Yuan|first20=Ye|last21=Chen|first21=Hua|last22=Li|first22=Huadong|last23=Huang|first23=Hanping|last24=Tu|first24=Shengjing|last25=Gong|first25=Fengyun|last26=Liu|first26=Ying|last27=Wei|first27=Yuan|last28=Dong|first28=Chongya|last29=Zhou|first29=Fei|last30=Gu|first30=Xiaoying|last31=Xu|first31=Jiuyang|last32=Liu|first32=Zhibo|last33=Zhang|first33=Yi|last34=Li|first34=Hui|last35=Shang|first35=Lianhan|last36=Wang|first36=Ke|last37=Li|first37=Kunxia|last38=Zhou|first38=Xia|last39=Dong|first39=Xuan|last40=Qu|first40=Zhaohui|last41=Lu|first41=Sixia|last42=Hu|first42=Xujuan|last43=Ruan|first43=Shunan|last44=Luo|first44=Shanshan|last45=Wu|first45=Jing|last46=Peng|first46=Lu|last47=Cheng|first47=Fang|last48=Pan|first48=Lihong|last49=Zou|first49=Jun|last50=Jia|first50=Chunmin|last51=Wang|first51=Juan|last52=Liu|first52=Xia|last53=Wang|first53=Shuzhen|last54=Wu|first54=Xudong|last55=Ge|first55=Qin|last56=He|first56=Jing|last57=Zhan|first57=Haiyan|last58=Qiu|first58=Fang|last59=Guo|first59=Li|last60=Huang|first60=Chaolin|last61=Jaki|first61=Thomas|last62=Hayden|first62=Frederick G.|last63=Horby|first63=Peter W.|last64=Zhang|first64=Dingyu|last65=Wang|first65=Chen|title=A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19|journal=New England Journal of Medicine|volume=382|issue=19|year=2020|pages=1787–1799|issn=0028-4793|doi=10.1056/NEJMoa2001282}}</ref> indicated partial success in treatment of [[COVID-19]].
 
* [[Remdesivir]] (100-200mg/day)<ref name="urlCoronavirus disease 2019 (COVID-19) investigational drug information for remdesivir">{{cite web |url=https://reference.medscape.com/drug/remdesivir-4000090 |title=Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir |format= |work= |accessdate=}}</ref>, a drug originally developed to treat [[Ebola virus]], showed positive results against [[SARS-CoV-2]].
OR
* [[Dexamethasone]] (6mg/day)<ref name="urlCorticosteroids | Coronavirus Disease COVID-19">{{cite web |url=https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/ |title=Corticosteroids &#124; Coronavirus Disease COVID-19 |format= |work= |accessdate=}}</ref> has been announced as an effective treatment in patients with systematic manifestations.
 
[Therapy] is recommended among all patients who develop [disease name].
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [disease name].


OR
* Surgical intervention is not recommended for the management of covid-19.
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
OR
There are no available vaccines against [disease name].
OR
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
OR
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
OR


Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
* Effective measures for the [[primary prevention]] of [[covid-19]] include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Latest revision as of 23:49, 12 December 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2], Fahimeh Shojaei, M.D.

Synonyms and keywords: MFS, fisher syndrome

Overview

Miller Fisher Syndrome (MFS) is an acute peripheral neuropathy that can develop after exposure to a viral or bacterial infection. It includes triad of ophthalmoplegia, areflexia and ataxia. In COVID-19 pandemic period, while COVID-19 typically presents with fever, shortness of breath (SOB) and respiratory symptoms, MFS with prior history of COVID-19 has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of COVID-19 patients have reported peripheral neurological symptoms.

Historical Perspective

  • The first reported case of MFS with a history of COVID-19 was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with areflexia, acute weakness in both legs and severe fatigue.
  • Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. [1]

Classification

Pathophysiology

Causes

Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • While the incidence of MFS is one or two-person per million each year, the prevalence of MFS associated with COVID-19 is still unknown.

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for patients with MFS caused by COVID-19.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • Although the diagnosis of COVID-19 is based on respiratory symptoms, it can be associated with neurological symptoms, which overlap the diagnosis of MFS.
  • Consequently, inpatient with prior history of COVID-19, other neurologic diseases should be ruled out and anti-GQ1b antibody test should be considered.
  • Also, in new patients with suspicious symptoms for COVID-19 and neurological symptoms, a nasal swab test and neurological examination should be considered.
  • MRI may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.[3]. [4]

History and Symptoms

Common symptoms

Less common symptoms

Physical Examination

  • Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:

Vitals

Abnormal signs associated with covid-19:

Neurological

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of COVID-19 include positive PCR nasal swab.
  • Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:

Electrocardiogram

X-ray

Echocardiography or Ultrasound

  • Lung ultrasound may be helpful in the evaluation of patients with COVID-19. It indicates :

CT scan

The preliminary findings of CT in COVID-19 associated with MFS include:

MRI

  • Brain MRI may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and neurological manifestations.
  • Although there can be no abnormalities, multiple cranial nerve enhancement has been reported in some patients.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with COVID-19 with MFS manifestations.

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of covid-19.

Primary Prevention

  • Effective measures for the primary prevention of covid-19 include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.

References

  1. ↑ {{https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619}}
  2. ↑ {{https://pubmed.ncbi.nlm.nih.gov/10695710}}
  3. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  4. ↑ {{https://rarediseases.org/rare-diseases/miller-fisher-syndrome/}}
  5. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  6. ↑ {{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/}}
  7. ↑ Cao, Bin; Wang, Yeming; Wen, Danning; Liu, Wen; Wang, Jingli; Fan, Guohui; Ruan, Lianguo; Song, Bin; Cai, Yanping; Wei, Ming; Li, Xingwang; Xia, Jiaan; Chen, Nanshan; Xiang, Jie; Yu, Ting; Bai, Tao; Xie, Xuelei; Zhang, Li; Li, Caihong; Yuan, Ye; Chen, Hua; Li, Huadong; Huang, Hanping; Tu, Shengjing; Gong, Fengyun; Liu, Ying; Wei, Yuan; Dong, Chongya; Zhou, Fei; Gu, Xiaoying; Xu, Jiuyang; Liu, Zhibo; Zhang, Yi; Li, Hui; Shang, Lianhan; Wang, Ke; Li, Kunxia; Zhou, Xia; Dong, Xuan; Qu, Zhaohui; Lu, Sixia; Hu, Xujuan; Ruan, Shunan; Luo, Shanshan; Wu, Jing; Peng, Lu; Cheng, Fang; Pan, Lihong; Zou, Jun; Jia, Chunmin; Wang, Juan; Liu, Xia; Wang, Shuzhen; Wu, Xudong; Ge, Qin; He, Jing; Zhan, Haiyan; Qiu, Fang; Guo, Li; Huang, Chaolin; Jaki, Thomas; Hayden, Frederick G.; Horby, Peter W.; Zhang, Dingyu; Wang, Chen (2020). "A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19". New England Journal of Medicine. 382 (19): 1787–1799. doi:10.1056/NEJMoa2001282. ISSN 0028-4793.
  8. ↑ "Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir".
  9. ↑ "Corticosteroids | Coronavirus Disease COVID-19".


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