Tetanus is a severe and potentially life-threatening infection caused by the bacterium Clostridium Tetani. It is a gram-negative anaerobe, often found in soil in spore form and in the gastrointestinal tract of humans and animals. It produces a potent neurotoxin called tetanospasmin. The presence of this toxin on the affected wound contributes to its pathogenesis. In developed countries such as the United Kingdom, tetanus poses a diagnostic challenge as cases are becoming scarce and, therefore, difficult to diagnose in an acute setting following the national immunisation programme in 1961. The prognosis of an acute tetanus can be derived from several risk-stratifying scoring systems such as the Tetanus Severity Score (TSS), with any score above 8 representing a 53% case-fatality rate. Prompt clinical diagnosis, immediate delivery of treatment and strict adherence to the national vaccination programme are paramount to suppress the incidence and the fatality rate from tetanus.

Miller Fisher syndrome (MFS) is a rare acquired neuropathy resulting from an acute infection and is believed to be a variant of Guillain-Barre syndrome (GBS). Its characteristic features are triads of ataxia, areflexia and ophthalmolegia, though involvement of cranial nerves is possible. Our case report describes a middle-aged man who presented as a potential stroke patient with left-sided facial droop, dysphagia and weakness. Upon in-depth clinical examination and basic investigations, stroke was deemed unlikely and clinical diagnosis of MFS was reached. This was further confirmed by the presence of anti-GQ1b antibody and anti-GT1a antibody in the serological study. Our patient was closely monitored with spirometry checks and only received supportive therapy throughout his treatment course until he achieved full clinical recovery. From this case we learnt that the clinical manifestations of MFS may vary depending on the presence of different types of autoantibodies. Similar to GBS, management of MFS is also largely supportive. Despite the widespread use of intravenous immunoglobulins with or without plasmapheresis to treat MFS, there is no conclusive evidence yet regarding prioritizing one treatment over another as the disease itself is self-limiting.