BACKGROUND Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome characterized by the classic triad of ophthalmoplegia, ataxia, and areflexia following a recent infection. Early recognition is particularly challenging due to the rarity of the condition and its tendency to mimic other common neurological and non-neurological disorders. We report a case highlighting the diagnostic and referral challenges encountered in the primary care setting. CASE REPORT A 38-year-old woman with no significant comorbidity presented to a primary care clinic with acute diplopia, right eye pain, headache, and perioral numbness following an upper respiratory tract infection 2 weeks earlier. Initial neurological examination was unremarkable. She was referred to the ophthalmology and emergency departments to exclude ocular pathology and posterior circulation stroke. Laboratory investigation and computed tomography of the brain were unremarkable and she was managed as a case of migraine. Meanwhile, ophthalmological review subsequently demonstrated ophthalmoplegia and the following day she developed bulbar symptoms prompting urgent neurological consultation. Repeated neurological examination revealed the classic triad of MFS. She received plasma exchange therapy following her clinical deterioration. Her neurological symptoms gradually improved with complete recovery, with residual diplopia resolving 8 weeks after symptom onset. CONCLUSIONS MFS remains a predominantly clinical diagnosis with subtle and evolving features that may delay recognition in the primary care setting. This case underscores the crucial role of primary care physicians in maintaining a high index of suspicion, recognizing atypical presentation, and providing appropriate safety-netting and timely specialist referral to facilitate early diagnosis and improve clinical outcomes.
Annual influenza vaccination is the most important preventive strategy against influenza illness in healthcare workers (HCWs), who could acquire influenza from and transmit influenza to patients and other HCWs. Despite the well established benefits and strong recommendations for influenza vaccination for all HCWs, influenza vaccination uptake at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) for the past 3 years has been low and is decreasing. We aimed to determine the factors associated with influenza vaccination uptake among HCWs at UKMMC. We conducted a cross sectional study via questionnaire among 211 randomly selected HCWs, consisting of 106 HCWs who were vaccinated in 2011 and 105 HCWs who were not vaccinated in 2010 or 2011. We had a 100% response rate. Influenza vaccination uptake was significantly associated with age and previous vaccination history, with older HCWs being more likely to be vaccinated (adjusted OR = 12.494; 95% CI:6.278-24.863; p < 0.001) and HCWs with previous vaccination history being more likely to be vaccinated (adjusted OR = 1.038; 95% CI:1.001-1.077; p = 0.045). Influenza vaccination uptake was not associated with gender (p = 0.926) or job category (p = 0.220). Publicity at the workplace was the main source of information about the vaccine (51.2% of respondents), followed by colleagues (29.9%). Despite the low uptake, 85.3% of respondents believed influenza vaccination was important for disease prevention. The most common reason given for vaccination was protection against influenza infection (73.6%). The most common reason for not having the vaccine was time constraints (56.2%). An evidenced-based strategy needs to be developed to improve vaccine uptake or having mandatory vaccination.