Bickerstaff’s Encephalitis

A middle-aged woman was admitted with drowsiness, weakness of all four limbs and visual impairment. Physical examination revealed that the patient had bilateral complete ophthalmoplegia, generalized weakness and spasticity,with brisk reflexes and bilateral upgoing plantar reflexes. A hyper-intense lesion at the level of the midbrain  was noted on cerebral MRI (Figure 1). Cerebro-spinal fluid examination was unremarkable and microbiological workup was negative. Serum for anti-GQ1b IgG antibodies were strongly positive. A diagnosis of Bickerstaff’s encephalitis was made and the patient was treated with immunotherapy in the form of plasmapharesis, after which she made a gradual recovery.