Clinical Commander

Back to dossier
neuro.gbs-miller-fisher.v1PRODUCTION
neuro.gbs-miller-fisher.v1

Miller-Fisher Syndrome (GBS variant)

neurologyacuteadultpediatric
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm MFS classic triad: ophthalmoplegia + ataxia + areflexia (Brighton 2011 PMID 24163275; van Doorn 2011 PMID 25023340)

Inputs
3
Actions
0
Advance rule
Set
Advance when

MFS triad confirmed; stroke/Wernicke excluded

Patient inputs (16)

Anti-GQ1b in ~85% MFS — highly specific (Wakerley 2016 PMID 25072194)

Age + geographic context — Taiwan/Japan ~25% of GBS is MFS vs ~5% Western (van Doorn 2011 PMID 25023340)

Respiratory infection (Haemophilus, CMV) in ~70% of MFS (van Doorn 2011)

External ± internal ophthalmoplegia — first MFS triad component (van Doorn 2011)

Ataxia — second MFS triad component; often gait + appendicular (van Doorn 2011)

Areflexia — third MFS triad component (Brighton 2011 PMID 24163275)

Albumino-cytologic dissociation — present in ~50% wk 1, less consistent in MFS than AIDP (AAN 2012)

IgA deficiency screen before IVIG (anaphylaxis risk) (EAN/PNS 2023)

Exclude brainstem stroke / Wernicke / Bickerstaff brainstem encephalitis (T2 brainstem hyperintensity) (Wakerley 2016)

Encephalopathy + brainstem signs → Bickerstaff overlap; ICU monitoring required (Wakerley 2016 PMID 25072194)

Bulbar weakness may indicate PCB overlap → airway concern (Wakerley 2016)

Respiratory monitoring — MFS less commonly requires MV but overlap variants may (AAN 2012)

NCS often normal in pure MFS; may show abnormalities in overlap MFS-GBS (van Doorn 2011)

Exclude transverse myelitis (NICE 2024)

Autonomic — paroxysmal tachy/brady (IGOS Doets 2018)

Autonomic BP swings (IGOS Doets 2018)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationalsevereBickerstaff_brainstem_overlap
    Bickerstaff brainstem encephalitis — MFS triad + encephalopathy + brainstem signs (hyperreflexia, central facial weakness) + anti-GQ1b+; T2 brainstem hyperintensity on MRI (Wakerley 2016 PMID 25072194)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepharyngeal_cervical_brachial
    PCB overlap variant — bulbar + neck + upper-limb weakness with sparing of legs; aspiration risk dominant; anti-GQ1b+ (Wakerley 2016 PMID 25072194)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereGBS_limb_weakness_overlap
    MFS-GBS overlap — MFS triad + limb weakness (typical GBS-pattern weakness); ~25% of MFS evolves to include limb involvement (van Doorn 2011 PMID 25023340)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateclassic_triad
    Classic MFS triad: ophthalmoplegia + ataxia + areflexia; ~85% anti-GQ1b+ (van Doorn 2011 PMID 25023340)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanti-GQ1b_positive
    Anti-GQ1b antibody positive — highly specific MFS / Bickerstaff / PCB serology marker (~85% of MFS, ~70% of Bickerstaff) (Wakerley 2016 PMID 25072194)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_MFS
    Pediatric MFS — same triad; weight-based IVIG; usually full recovery; consider pediatric neurology + ophthalmology referral (van Doorn 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmonophasic_typical
    Typical MFS course — monophasic with full recovery in 2-6 mo; relapse rare (<3%); reassuring prognostic anchor (van Doorn 2011 PMID 25023340)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
Loading…

Recommended regimen

MFS — IVIG preferred (per Cochrane subgroup); supportive + overlap-variant monitoring (Hughes Cochrane 2014 PMID 25238327; EAN/PNS 2023)
axis: mfs_acute_immunomodulation_supportivestep 1 - Step 1 — Acute immunomodulation (IVIG preferred per EAN/PNS 2023)
Selected step "Step 1 — Acute immunomodulation (IVIG preferred per EAN/PNS 2023)" — MFS Brighton 1-3 with progressive triad or overlap variant; IgA documented
  • ivig
    first line
    pooled_human_IgG
    0.4 g/kg/d × 5 d (total 2 g/kg) • IV • daily × 5 d (max: 2 g/kg cumulative)
    triggers: mfs_triad, overlap_bickerstaff_pcb_gbs
    EAN/PNS 2023 — IVIG preferred for MFS (Cochrane MFS subgroup PMID 25238327); check IgA pre-IVIG
    rxcui 1426680
  • plasmapheresis (PLEX)
    second line
    apheresis
    5 sessions over 7-10 d (q48h) • IV • 5 sessions q48h
    triggers: iga_deficient, ivig_unavailable, severe_overlap
    Raphael Cochrane PMID 22786475 — alternative; less evidence specifically in pure MFS (EAN/PNS 2023)

outpatient playbook — drug actions (1)

  1. 1. gabapentin / pregabalin taper
    Per pain response • PO • taper
    trigger: Pain resolving
    NICE 2024

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Classic MFS triad: ophthalmoplegia + ataxia + areflexia (van Doorn 2011 PMID 25023340); Anti-GQ1b antibodies positive — ~85% of MFS (highly specific) (Wakerley 2016 PMID 25072194); Bickerstaff brainstem encephalitis overlap — MFS triad + encephalopathy + brainstem signs; same anti-GQ1b+ spectrum (Wakerley 2016).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Miller-Fisher Syndrome (GBS variant)** (neuro.gbs-miller-fisher.v1).
Phenotype framing: MFS (this engine) vs MG (anti-AChR; fluctuating fatigability) vs Wernicke (thiamine-responsive) vs brainstem stroke vs botulism vs AIDP (limb weakness predominant) vs Bickerstaff/PCB (anti-GQ1b spectrum) (Wakerley 2016)
Scope: Confirm MFS classic triad: ophthalmoplegia + ataxia + areflexia (Brighton 2011 PMID 24163275; van Doorn 2011 PMID 25023340)

No severity triggers fired against current inputs.

Plan

Regimen axis: **MFS — IVIG preferred (per Cochrane subgroup); supportive + overlap-variant monitoring (Hughes Cochrane 2014 PMID 25238327; EAN/PNS 2023)** — step "Step 1 — Acute immunomodulation (IVIG preferred per EAN/PNS 2023)".
1. ivig 0.4 g/kg/d × 5 d (total 2 g/kg) IV daily × 5 d (pooled_human_IgG, first line) — EAN/PNS 2023 — IVIG preferred for MFS (Cochrane MFS subgroup PMID 25238327); check IgA pre-IVIG
2. plasmapheresis (PLEX) 5 sessions over 7-10 d (q48h) IV 5 sessions q48h (apheresis, second line) — Raphael Cochrane PMID 22786475 — alternative; less evidence specifically in pure MFS (EAN/PNS 2023)

Setting playbook (outpatient) — Post-acute MFS — neuro-ophthalmology follow-up for ophthalmoplegia resolution; gait/balance therapy; usually monophasic full recovery 2-6 mo (van Doorn 2011)
3. gabapentin / pregabalin taper Per pain response PO taper — Pain resolving (NICE 2024)

Non-pharmacologic actions:
- Continued PT/OT for balance + gait (NICE 2024)
- Neuro-ophthalmology for residual diplopia (van Doorn 2011)
- Vaccine timing discussion with neurology (NICE 2024)
- Driving assessment when ophthalmoplegia resolved (NICE 2024)

AVOID / contraindication checks:
- No_steroids_alone_for_GBS_MFS (Hughes Cochrane 2014)
- Check_IgA_before_IVIG (EAN/PNS 2023)
- Avoid_succinylcholine_use_rocuronium_with_sugammadex (AAN 2012)
- DVT_prophylaxis_if_immobile (EAN/PNS 2023)
- Do_not_combine_IVIG_and_PLEX (Hughes Cochrane 2014)
- Exclude_brainstem_stroke_thiamine_deficiency_before_assigning_MFS (Wakerley 2016)

Monitoring

Regimen monitoring:
- Cranial nerve exam q4-6h for overlap evolution (Wakerley 2016)
- FVC NIF q4-6h if overlap variant (AAN 2012)
- Continuous ECG for autonomic (IGOS Doets 2018)
- BP q4h or q1-2h if autonomic signs (IGOS Doets 2018)
- Anti-GQ1b result when back (Wakerley 2016)
- IVIG AE TRALI aseptic meningitis thrombosis (EAN/PNS 2023)
- Watch for treatment related fluctuation weeks 2-3 (EAN/PNS 2023)

Setting (outpatient) monitoring:
- Recovery at 2 wk, 6 wk, 3 mo, 6 mo (NICE 2024)
- CIDP-like recurrence rare in MFS — but document if happens (van Doorn 2011)

Follow-up plan: Neuro-ophthalmology follow-up for ophthalmoplegia resolution; gait/balance therapy; usually monophasic full recovery in 2-6 mo (van Doorn 2011)
- Close-out criterion: Follow-up bundle scheduled

Monitoring phase: Q4-6h neuro exam for overlap evolution; FVC if bulbar/limb; serial cranial nerve exam; watch for treatment-related fluctuation (EAN/PNS 2023)

Disposition

Current setting: outpatient — Post-acute MFS — neuro-ophthalmology follow-up for ophthalmoplegia resolution; gait/balance therapy; usually monophasic full recovery 2-6 mo (van Doorn 2011)

Disposition criteria:
- Routine outpatient follow-up; usually full recovery in 2-6 mo (van Doorn 2011)

Escalation triggers (move to higher acuity):
- New deficit or worsening >4 wk → MS / CIDP / NMOSD reconsideration (van Doorn 2011)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Bickerstaff brainstem encephalitis — MFS triad + encephalopathy + brainstem signs (hyperreflexia, central facial weakness) + anti-GQ1b+; T2 brainstem hyperintensity on MRI (Wakerley 2016 PMID 25072194)
- [SEVERE] PCB overlap variant — bulbar + neck + upper-limb weakness with sparing of legs; aspiration risk dominant; anti-GQ1b+ (Wakerley 2016 PMID 25072194)
- [SEVERE] MFS-GBS overlap — MFS triad + limb weakness (typical GBS-pattern weakness); ~25% of MFS evolves to include limb involvement (van Doorn 2011 PMID 25023340)

Citations

- 2023 EAN/PNS GBS Guideline + Hughes Cochrane 2014 + Wakerley 2016 anti-GQ1b syndromes spectrum [PMID:25238327](https://pubmed.ncbi.nlm.nih.gov/25238327/)
- Cited evidence (PMID 22786475) [PMID:22786475](https://pubmed.ncbi.nlm.nih.gov/22786475/)
- Cited evidence (PMID 25023340) [PMID:25023340](https://pubmed.ncbi.nlm.nih.gov/25023340/)
- Cited evidence (PMID 25072194) [PMID:25072194](https://pubmed.ncbi.nlm.nih.gov/25072194/)
- Cited evidence (PMID 24163275) [PMID:24163275](https://pubmed.ncbi.nlm.nih.gov/24163275/)

Last reconciled with current guidelines: 2026-05-22.
References