A combined presentation of Graves' disease and Miller-Fisher syndrome

Repeat MRI of the head showed thickened and contrast-medium-enhanced eye muscles, especially of the inferior rectus muscle, and contrast enhancement of the periorbital adipose tissue, and oculomotor and facial nerves (figure, left). Molecular mimicry may have a significant role in lhe onset of the Miller-Fisher syndrome, since the GQ1b epitope has been found in lipopolysaccharides of Campylobocter jejuni.4 Therapeutic regimens for the Miller-Fisher syndrome include treatment with intravenous immunoglobulin and plasmapheresis to remove the antibodies to GQ1b, although the rate of spontaneous recovery is high.5 Our patient had a mild form of Graves' disease-the thickened eye muscles visible on MRI were compatible with the presence of an endocrine ophthalmopathy, but the pattern of limited eye movement was atypical and is better explained by the coinciding presence of Miller-Fisher syndrome.