Introduction: The differential diagnosis of patients
presenting with multiple cranial neuropathies, ataxia, and altered mentation
is broad and includes immunologic, infectious, vasculitic and metabolic
conditions. Primary considerations are Bickerstaff’s brainstem encephalitis (BBE),
the Miller Fisher syndrome (MFS), Wernicke’s encephalopathy and botulism. The
initial workup may be unrevealing. Timely treatment is imperative and
unnecessary treatment can be associated with serious adverse reactions.
Sensitivity to the decisions needed in such patients is therefore important.
Case report: A 58-year-old male presented with symptoms of altered mental
status, blurred vision, dysphagia and dysarthria, impaired pupillary
responses to light, facial diplegia, ataxia, and decreased tendon reflexes
after an episode of a self resolving diarrheal disease. Primary initial
diagnostic concerns were Bickerstaff’s brainstem encephalitis (BBE), Miller
Fisher syndrome (MFS), Wernicke’s encephalopathy and botulism. Initial work-up
including cerebrospinal fluid analyses, imaging studies, and an
electrodiagnostic examination did not provide information helpful for narrowing
this differential. The patient was treated with botulinum antitoxin, thiamine
and intravenous immune globulin (IVIG) before the results of specialized
tests were available. The patient’s clinical condition improved. Retrospectively,
the patient was diagnosed as BBE. Conclusion: This case emphasizes the difficulties
in distinguishing between BBE, MFS, and botulism as well as demonstrating the
complexities of treating such patients.