Acute cerebellitis caused by herpes simplex virus

Case presentation of acute cerebellitis caused by herpes simplex virus.

Cryptococcal cerebellitis in no-VIH patient / Cerebelitis criptococócica en paciente VIH negativo

Abstract Introduction: Cryptococcosis is an opportunistic fungal infection whose etiology is Cryptococcus neofromans / C. gattii, complex which affects immunocompromised patients mainly. Meningeal infection is one of the most common presentations, but cerebellar affection is rare. Case Description: Male patient with 65 old years, from an area of subtropical climate with chronic exposure to poultry, without pathological antecedents, who presented clinical picture consistent with headache, fever, seizures and altered mental status. Clinical findings and diagnostic methods: Initially without menigeal signs or intracranial hypertension and normal neurological examination. Later, the patient developed ataxia, dysdiadochokinesia and limb loss. By lumbar punction and image of nuclear magnetic resonance (NMR) cerebellitis cryptococcal was diagnosticated. Treatment: Antifungal therapy with amphotericin B and fluconazole was performed, however the patient died. Clinical Relevance: The cryptococcosis has different presentations, it´s a disease whose incidence has been increasing since the advent of the HIV / AIDS pandemy, however the commitment of the encephalic parenchyma and in particular the cerebellum is considered rare. In this way we are facing the first case of cryptococcal cerebellitis in our midst.

Resumen Introducción: La Criptococosis es una infección micótica oportunista cuya etiología es el complejo Cryptococcus neofromans/C. gattii, el cual principalmente afecta pacientes inmunocomprometidos. La afección meníngea es una de las formas más frecuentes pero el compromiso cerebeloso es raro. Descripción del Caso: Paciente masculino de 65 años, procedente de un área rural con exposición crónica a aves de corral, sin antecedentes patológicos, con cuadro clínico inicial consistente en cefalea crónica, fiebre, convulsiones y alteración del estado mental. Hallazgos clínicos y métodos diagnósticos: Al principio sin signos de hipertensión intracraneana ni meníngeos y examen neurológico normal, con posterior desarrollo de ataxia, disdiadococinesia y dismetría. Se diagnosticó Cerebelitis Criptocococica con ayuda de repetidos estudios de LCR y resonancia magnética nuclear. Tratamiento: Se inició terapia antifúngica con Anfotericina B y Fluconazol, con respuesta tórpida y el paciente fallece. Relevancia clínica: La Cerebelitis Criptocococica es una presentación clínica infrecuente que requiere sospecha clínica y recursos diagnósticos para definir el tratamiento de forma temprana. La inmunosupresión no es requisito para padecer esta infección.

Hipoplasia pontocerebelosa secundaria a deleción en el gen CASK: Caso clínico / Pontocerebellar hypoplasia secondary to CASK gene deletion: Case report

Introducción: La hipoplasia pontocerebelosa (HPC) es la reducción del tamaño del cerebelo y la protuberancia secundaria a una alteración en su desarrollo, pudiendo ser provocado por enfermedades neurodegenerativas de causa genética, de las que se conocen 10 subtipos (PCH 1-10), malformaciones corticales, enfermedades metabólicas y enfermedades genéticas. Objetivo: Presentar el caso de una niña con microcefalia, HPC y Síndrome de West, en que el estudio genético permitió llegar al diagnóstico de una deleción en el cromosoma X. Caso clínico: Lactante de 7 meses al diagnóstico, sin antecedentes familiares ni obstétricos de interés, perímetro cefálico (PC) al nacimiento en -1.5 desviaciones estándar (DE). Evolucionó con escasa progresión ponderal y estancamiento del crecimiento del PC, retraso del desarrollo psicomotor, caracterizado por ausencia de fijación de la mirada e hipotonía con reflejos osteotendinosos conservados, y epilepsia refractaria. En los potenciales evocados auditivos se demostró compromiso de las vías pontomesencefálicas y en las neuroimágenes HPC. El estudio genético Array de Hibridación Genómica Comparada (aCGH) demostró deleción parcial heterocigota en el cromosoma X, afectando al gen CASK. Conclusiones: Ante el amplio diagnóstico diferencial que plantea las HPC, las nuevas técnicas citogenéticas han permitido mejorar la clasificación y en algunos casos establecer su etiología, pudiendo ofrecer en estos casos un adecuado asesoramiento genético a las familias.

Introduction: Pontocerebellar hypoplasia (PCH) is a reduction of the size of the cerebellum and pons secondary to an alteration in its development, and can be caused by neurodegenerative diseases of genetic origin, of which there are known 10 subtypes (PCH 1-10), cortical malformations, metabolic and genetic diseases. Objective: To present the case of a child with microcephaly, PCH and West syndrome, in which the genetic study allowed to make the diagnosis of a deletion on chromosome X. Case report: This is a female infant of 7-month at diagnosis, without family or obstetric history of interest, head circumference at birth -1.5 standard deviations (SD). She had little weight and growth in head circumference progression. In addition, physical examination revealed no fixating gaze, hypotonia with preserved deep tendon reflexes. Progressively developed refractary seizures. Brainsteam Auditory Evoked Potential demonstrated involvement of pontomesencefphalic ways and neuroimaging Pontocerebellar hypoplasia. The genetic study (aCGH) showed heterozygous deletion on the X chromosome, affecting the CASK gene. Conclusions: Given the wide differential diagnosis proposed at the PCH, new cytogenetic techniques have improved the classification of HPC and in some cases establish their etiology, so in these cases can provide appropriate genetic counseling to families.

Síndrome de Joubert / Joubert syndrome

El Síndrome de Joubert (SJ) es un raro trastorno autosómico recesivo con una incidencia de 1/100 000 a 1/150 000 nacidos vivos, considerado una ciliopatia que muestra tubulopatía renal, inmunodeficiencia y trastorno de la migración neuronal en cerebelo y tronco encefálico. El criterio diagnóstico más saltante es el “Signo del Molar” detectado por resonancia magnética cerebral, que identifica hipoplasia de los pedúnculos y vermis cerebeloso. Hasta el momento se han descrito seis subgrupos fenotípicos: SJ puro; SJ con defecto ocular (distrofia retiniana); SJ con defectos renales (no asociados a patolog¡a retiniana); SJ con defectos óculorrenales; SJ con defecto hepático y SJ con defectos orofaciodigitales (por ejemplo, lengua bífida, hamartomas múltiples, múltiples frenillos orales y polidactilia). La importancia de un diagnóstico precoz del SJ se puede reflejar en un posible mejor pronóstico y en la posibilidad de mejorar la calidad de vida del paciente con un manejo multidisciplinario y consejo genético para la prevención de nuevos casos en familias afectadas.

The Joubert Syndrome (JS) is a rare autosomal recessive disorder with an incidence of 1 / 100000 to 1/150 000 births, considered a ciliopathy and showing renal tubular disease, immunodeficiency and impaired neuronal migration in the cerebellum and brain stem. The main diagnostic criterion is the identification of the “Molar sign” through cerebral magnetic resonance that identifies hypoplasia of cerebellar vermis and peduncles. So far six phenotypic subgroups have been described: JS pure; JS with ocular defect (retinal dystrophy); JS with kidney defects (not associated with retinal pathology); JS with oculorrenal defects; JS with liver defect, and JS with orofaciodigital defects (eg, split tongue, multiple hamartomas, multiple oral frenums and polydactyly). The importance of diagnosing JS at an early stage is related to a possibly better prognosis, and the possibility of improving the patient’s quality of life by means of a multidisciplinary management and provision of genetic counseling for prevention of new cases in affected families.

Non-progressive cerebellar ataxia and previous undetermined acute cerebellar injury: a mysterious clinical condition / Ataxias cerebelares não-progressivas e lesão cerebelar aguda prévia indeterminada: uma condição clínica misteriosa

Cerebellar ataxias represent a wide group of neurological diseases secondary to dysfunctions of cerebellum or its associated pathways, rarely coursing with acute-onset acquired etiologies and chronic non-progressive presentation. We evaluated patients with acquired non-progressive cerebellar ataxia that presented previous acute or subacute onset. Clinical and neuroimaging characterization of adult patients with acquired non-progressive ataxia were performed. Five patients were identified with the phenotype of acquired non-progressive ataxia. Most patients presented with a juvenile to adult-onset acute to subacute appendicular and truncal cerebellar ataxia with mild to moderate cerebellar or olivopontocerebellar atrophy. Establishing the etiology of the acute triggering events of such ataxias is complex. Non-progressive ataxia in adults must be distinguished from hereditary ataxias.

Ataxias cerebelares representam um grupo amplo de doenças neurológicas secundárias a disfunções cerebelares ou das vias associadas, raramente cursando com etiologias adquiridas de início agudo e com evolução crônica não-progressiva. Nós avaliamos pacientes com ataxia cerebelar adquirida não-progressiva com apresentação prévia aguda ou subaguda. Foi realizada caracterização clínica e de neuroimagem de pacientes adultos com ataxia adquirida não-progressiva. Cinco pacientes foram identificados com o fenótipo clínico de ataxia adquirida não-progressiva. A maior parte dos pacientes apresentou início juvenil ou no adulto, de forma aguda ou subaguda, de ataxia cerebelar appendicular e de tronco com atrofia cerebelar ou olivopontocerebelar leve a moderada. Estabelecer a etiologia dos eventos agudos desencadeantes de tais ataxias é complexo. Ataxia não-progressiva em adultos deve ser diferenciada das ataxias hereditárias.

Síndrome cerebeloso cognitivo-afectivo / Cerebellar cognitive affective syndrome

Introducción. El diagnóstico de síndrome cerebeloso cognitivo afectivo se debe realizar en aquellos pacientes con lesiones cerebelosas y con déficit cognitivo asociado a deficiencias neuropsicológicas visoespaciales o ejecutivas, trastornos del lenguaje expresivo y trastornos afectivos. Caso clínico. Adolescente de 16 años diagnosticada con trastorno por déficit de atención e hiperactividad a los 7 años, que presenta inestabilidad emocional, apatía y discurso y lectura poco fluidos. Se observan deficiencias visoespaciales en los tests neuropsicológicos. Se realiza una resonancia magnética cerebral por presentar alteración de la coordinación y motricidad fina, y se evidencia atrofia de vermis cerebeloso. La sintomatología es compatible con síndrome cerebeloso cognitivo afectivo. Clásicamente, el cerebelo es conocido por su rol motor. Sin embargo, está implicado en funciones cognitivas superiores, en la expresión emocional y en la regulación conductual. El síndrome cerebeloso cognitivo afectivo es una entidad no bien conocida que debemos incluir en el diagnóstico diferencial de trastornos neuropsiquiátricos con lesión cerebelar.

Introduction. The diagnosis of Cerebellar Cognitive Affective Syndrome should be considered in patients with cerebellar lesions who also suffer cognitive deficits associated with visuospatial or executive neuropsychological disorders, expressive language disorders and affective disorders. Clinical case. A 16 year old adolescent diagnosed with Attention Deficit Hyperactivity Disorder at the age of 7 presents with emotional instability, apathy, and speech and reading difficulties. Neuropsychological tests show visuospatial difficulties. A brain magnetic resonance imaging is performed due to impaired coordination and fine motor movements and shows atrophy of the cerebellar vermis. The clinical picture suggests a diagnosis of Cerebellar Cognitive Affective Syndrome. The cerebellum is mostly known for its motor role. However, it is also involved in higher cognitive functions, expression of emotion and behavioral regulation. Cerebellar Cognitive Affective Syndrome is a relatively unknown diagnosis and should be included in the differential diagnosis of neuropsychiatric disorders with cerebellar lesion.

Ectopia amigdalina cerebelosa borderline en un niño con cefalea. Caso clínico / Borderline cerebellar tonsillar ectopia in a child with headache. Case report

La cefalea es un síntoma que conlleva un malestar signifcativo y deterioro funcional en quienes lo sufren con frecuencia, tanto en la infancia como en la edad adulta. Algunas afecciones se asocian con una mayor frecuencia de cefaleas. La ectopia amigdalina cerebelosa borderline, defnida como la protrusión de las amígdalas cerebelosas por foramen magnum), es una de esas afecciones. Aunque no está claro el signifcado clínico de esta entidad como causa de cefalea, hay estudios que informaron su asociación en el 16% de los pacientes. Se presenta el caso de un paciente de 9 años que acudió a la consulta por padecer una cefalea frontal de 5 años de evolución. Se diagnosticó ectopia amigdalina cerebelosa borderline mediante una resonancia magnética. Se describe este caso dado lo atípico de la presentación de esta entidad en la infancia.

Frequent headache is a symptom that leads to signifcant distress and functional impairment, both in childhood and in adulthood. Some medical conditions are associated with a higher frequency of headaches. Borderline cerebellar tonsillar ectopia which may be defned as the downward extension of cerebellar tonsils of < 5 mm below the foramen magnum is among these conditions. Although questions persist about the clinical signifcance of this rare entity on headache, there are studies reporting severe headache syndrome in 16% of these patients. We report a 9-year old male patient, who presented to our clinic with a frontal headache of 5 years' duration, and was found to have borderline cerebellar tonsillar ectopia on magnetic resonance imaging. To the best of our knowledge, there has not been a reported case of this coexistence at this early stage of life. We would like to contribute to the literature, owing to the very rare and atypical presentation of this entity in the early childhood period.

A Case of Cerebellar Infarction Caused by Acute Subclavian Thrombus Following Minor Trauma

Subclavian steal syndrome caused by an acute thrombus is very rare. We present a case of cerebellar infarction with proximal subclavian artery thrombosis. A 56-year-old woman was admitted for sudden vertigo. One day prior to admission, she received a shoulder massage comprised of chiropractic manipulation. On examination, her left hand was pale and radial pulses were absent. Blood pressure was weak in the left arm. Downbeat nystagmus and a right falling tendency were observed. Brain MRI showed multiple acute infarctions in the left cerebellum. The findings of Doppler ultrasonography in the left vertebral artery were compatible with a partial subclavian artery steal phenomenon. Digital subtraction angiography demonstrated a large thrombus in the left subclavian artery. After heparin infusion, thrombus size markedly decreased. Cerebellar infarction caused by acute subclavian thrombosis following minor trauma is rare, but the thrombus can be successfully resolved with anticoagulation.

Vestibulo-ocular reflex and the head impulse test / Reflexo vestíbulo-ocular e o teste do impulso da cabeça

The authors highlights the importance of the vestibulo-ocular reflex examination through the head impulse test as a diagnostic method for vestibular dysfunction as well as, and primarily, a bedside semiotic resource capable of differentiating between acute peripheral vestibulopathy and a cerebellar or brainstem infarction in emergency rooms.

Os autores ressaltam a importância do exame do reflexo vestíbulo-ocular por meio do teste do impulso da cabeça como método diagnóstico de hipofunção vestibular. Este método é também - e principalmente - um instrumento semiótico de beira do leito capaz de auxiliar no diagnóstico diferencial entre a vestibulopatia periférica aguda e o infarto cerebelar ou do tronco cerebral na sala de emergência.

Quistes epidermoides del ángulo pontocerebeloso: experiencia en 43 casos con seguimiento a largo plazo / Cerebellopontine angle epidermoid cysts: experience of 43 cases with long-term follow-up

Introducción: El quiste epidermoide ocupa el tercer lugar de los tumores en la región del ángulo pontocerebeloso. El presente informe describe los principales aspectos clínicos, radiológicos y el manejo quirúrgico de este tipo de quistes en esa ubicación. Material y métodos: Serie de pacientes operados de quiste epidermoide del ángulo pontocerebeloso entre 1998 y 2005. Se clasificó la extensión de la lesión según las cisternas involucradas: extensión I, limitada al ángulo pontocerebeloso; extensión II, cisternas ángulo pontocerebeloso + supraselar + perimesencefálicas; extensión III, ángulo pontocerebeloso con extensión paraselar y temporomesial. Resultados: 43 pacientes con seguimiento promedio de 85 meses, la edad media fue de 34 años; 67 % fue del sexo femenino. Los principales síntomas fueron cefalea (58.1 %) y afección trigeminal (41.8 %). De acuerdo con nuestra clasificación, los pacientes con extensión temporomesial (25.6 %) presentaron mayor incidencia de epilepsia secundaria (p = 0.001), y aquellos con neuralgia del trigémino tuvieron lesiones más limitadas al ángulo pontocerebeloso (p = 0.006). El abordaje más empleado fue el retrosigmoideo (39.5 %); la resección tumoral fue completa en 65 % de los pacientes. Conclusiones: Existen diferencias en la presentación clínica, grado de resección quirúrgica y recurrencia tumoral entre las diferentes extensiones del quiste epidermoide del ángulo pontocerebeloso, por lo que se requiere abordaje terapéutico específico. Para que las comparaciones entre series sea válida, es deseable el consenso y la elaboración de una clasificación consensuada acerca las extensiones del quiste epidermoide en esa ubicación.

BACKGROUND: Epidermoid tumors represent the third most common lesion of the cerebellopontine angle (CPA). Their evolution and clinical features are distinctively characteristic. We present a comprehensive review of the clinical, imaging and surgical aspects of epidermoid cysts of the CPA. METHODS: We conducted a case series of patients diagnosed with epidermoid cyst of the CPA who were operated on between 1998 and 2005. Lesions were classified according to their anatomic extent: grade I(-) within the boundaries of the CPA, grade II(-) extension to the suprasellar and perimesencephalic cisterns, and grade III(-) parasellar and temporomesial region involvement. RESULTS: This study was comprised of 43 patients with a mean follow-up of 85 months. Mean age was 34 years, and 67% of the patients were female. The initial symptom was headache in 58.1% of the cases and trigeminal neuralgia in 41.8%. According to our classification, temporomesial involvement (25.6%) was significantly (p = 0.001) associated with a higher incidence of seizures, and trigeminal neuralgia was present in patients with lesions limited to the CPA (p = 0.006). The lesions were reached essentially through a retrosigmoidal approach (39.5%) and surgical excision was deemed to be complete in 65% of the cases. CONCLUSIONS: Our grading classification according to the anatomic extension correlates well with clinical presentation, type of surgical approach and extent of surgical removal. It is desirable to reach a consensus on the classification of tumor extension.

Infarto pseudotumoral del cerebelo / Malignant cerebellar infarction

El diagnóstico de infarto cerebeloso en su presentación inicial puede ser difícil, su reconocimiento tardío puede asociarse a graves complicaciones. Aunque sólo representa 2 por ciento a 3 por ciento de los infartos encefálicos, afecta a un importante número de pacientes, muchos de los cuales son jóvenes. De todos los infartos de cerebelo sólo 10 por ciento evolucionará en forma maligna, siendo denominado infarto pseudotumoral de cerebelo. Las causas más habituales son la embolia, la disección de la arteria vertebral y la aterotrombosis. La arteria cerebelosa póstero-inferior es la más frecuentemente comprometida, y en un tercio de los casos se encuentra una fuente cardioembólica. Su rasgo distintivo es el efecto de masa, el mismo que ocasiona compresión de troncoencéfalo e hidrocefalia aguda, generando un deterioro cuantitativo de conciencia. Las neuroimágenes, tomografía computada y resonancia magnética de encéfalo, son de vital importancia para establecer la presencia de un infarto cerebeloso e identificar potenciales complicaciones. Es importante recordar que la tomografía computada es menos sensible que la resonancia magnética para establecer el diagnóstico. El manejo especializado multidisciplinario y la implementación de las medidas de soporte generales y específicas pueden mejorar las posibilidades de sobrevida y recuperación funcional. Ante la presencia de un deterioro de conciencia, un abordaje quirúrgico agresivo pareciera ser la mejor opción de tratamiento.

The diagnosis of cerebellar infarction at initial presentation can be difficult, delayed recognition can be associated with serious complications. Although representing only 2 percent to 3 percent of brain infarcts, affects a significant number of patients, many of whom are young. Only 10 percent of cerebellar infarcts evolve into malignant form, being named pseudotumoral cerebellar infarction. Common causes include embolism, vertebral artery dissection and atherothrombosis. The postero-inferior cerebellar artery is the most frequently committed, and one third of cases there is a cardioemboIic sourse. Its distinguishing feature is the mass effect, causing brain stem compression and acute hydrocephalus, and generating a quantitative impairment of consciousness. The brain imaging, computed tomography and magnetic resonance imaging of brain, are of vital importance to establish the presence of a cerebellar infarct and identify potential complications. It is important to remember that computed tomography is less sensitive than magnetic resonance for diagnosis. The multidisciplinary specialized management and implementation of measures of general and specific support can improve the chances of survival and functional recovery. In the presence of impaired consciousness, an aggressive surgical approach appears to be the best treatment option.

The Patterns of Clinical Presentations of Cerebellar Syndromes among Adult Sudanese Patients

Cerebellar syndromes are one of the commonest neurological diseases.Objectives:To study the patterns of clinical presentations of cerebellar syndromes and to identify the possible causes.Methods:This is a prospective hospital based; cross-sectional study. One hundred adult Sudanese patients with cerebellar syndromes were included in the study during the period from January 2006 January 2007.Results:The most common age group affected was 18 - 25 years.Male to female ratio was 1.5:1unsteadiness on walking was the most common symptom (83).Gait-ataxia was the most common sign (83). Cerebrovascular disease was the most common etiology (25).Conclusion:Cerebellar syndromes are not rare in Sudan.However; they were diagnosed more commonly at the central regions of the country probably because of more awareness of patients and better facilities for diagnosis.The age of onset; the male predominance; the presentation and clinical findings were not different from reported literature.This also goes for the common causes apart from alcohol which is a strikingly rare as a cause in this study and could be accounted for the implementation of Elshariya (Islamic laws) Laws in Sudan

Síndrome cerebeloso secundario a granulomas de fosa posterior y tuberculosis multisistémica en un paciente con SIDA / Cerebelous syndrome by infratentorial brain tuberculornas and mutisystemic tuberculosis in AIDS patient

Presentamos el caso clínico de un paciente que consultó por un síndrome cerebeloso y diplopía, asociados a pérdida de peso de 10 kilos en 6 meses y adenopatías múltiples. El estudio imagenológico cerebral demostró la presencia de lesiones de aspecto granulomatoso a nivel cerebeloso y mesencefálico, sin alteración citoquímica del líquido cefalorraquídeo. Las baciloscopias de orina y de la biopsia ganglionar fueron positivas y permitieron el diagnóstico de tuberculosis (TBC) sistémica. La serología para VIH resultó positiva en sangre con un recuento de linfocitos CD4 de 590 cel/mm3, clasificándose el caso como SIDA etapa Cl. El paciente fue tratado con el esquema antituberculoso según norma nacional, con buena respuesta clínica e imagenológica. La presentación de tuberculomas infratentoriales sin meningitis, como primera causa de pesquisa de TBC y SIDA no es habitual, de allí nuestro interés por comunicar el caso.

We present a clinical case of a patient who consulted for a cerebelous syndrome and diplopia associated to 10 kg weight loss in six months and multiple adenopathies. Cerebral imagenology study evidenced the presence of granulamatous masses at the cerebellum and midbrain level, there were no cerebrospinal fluid abnormalities. Systemic tuberculosis (TB) diagnosis was done based in finding of acid-fast bacilli positive staining in urine and lymph node biopsy. HIV infection was documented by ELISA serology. CD4 cell count was 590 cell/mm3, classifying the case a AIDS Cl stage. TB was treated according to national guidelines leading to good clinical and imagenology evolution. The clinical case scenario of infratentorial tuberculomas without meningitis as a first manifestation of TB and AIDS is unusual, generating our interest in reporting this case.

Neurological manifestation of methyl bromide intoxication.

Methyl bromide is a highly toxic gas with poor olfactory warning properties. It is widely used as insecticidal fumigant for dry foodstuffs and can be toxic to central and peripheral nervous systems. Most neurological manifestations of methyl bromide intoxication occur from inhalation. Acute toxicity characterized by headache, dizziness, abdominal pain, nausea, vomiting and visual disturbances. Tremor, convulsion, unconsciousness and permanent brain damage may occur in severe poisoning. Chronic exposure can cause neuropathy, pyramidal and cerebellar dysfunction, as well as neuropsychiatric disturbances. The first case of methyl bromide intoxication in Thailand has been described. The patient was a 24-year-old man who worked in a warehouse of imported vegetables fumigated with methyl bromide. He presented with unstable gait, vertigo and paresthesia of both feet, for two weeks. He had a history of chronic exposure to methyl bromide for three years. His fourteen co-workers also developed the same symptoms but less in severity. Neurological examination revealed ataxic gait, decreased pain and vibratory sense on both feet, impaired cerebellar signs and hyperactive reflex in all extremities. The serum concentration of methyl bromide was 8.18 mg/dl. Electrophysilogical study was normal. Magnetic resonance imaging of the brain (MRI) revealed bilateral symmetrical lesion of abnormal hypersignal intensity on T2 and fluid-attenuation inversion recovery (FLAIR) sequences at bilateral dentate nuclei of cerebellum and periventricular area of the fourth ventricle. This incident stresses the need for improvement of worker education and safety precautions during all stages of methyl bromide fumigation.

Cerebellar degeneration and immune thrombocytopenic purpura associated with human immunodefi ciency virus infection (HIV)

Cerebellar disorders associated with HIV infection are usually caused by opportunistic infections, central nervous system lymphoma, and toxic effects of medicines, nutritional and metabolic disorders, and cerebrovascular disease. We present an unusual association of cerebellar degeneration and immune thrombocytopenic purpura in a 28-years-old woman HIV infected. An autoimmune aetiology is likely.

Transtornos cerebelares associados a infecção pelo HIV são comumente causados por infecções oportunistas, linfoma do sistema nervoso central, efeitos tóxicos de medicamentos anti-retrovirais, alterações metabólicas e nutricionais, e doença cerebrovascular. Apresentamos um caso incomum de associação de degeneração cerebelar e púrpura trombocitopênica imunológica em um mulher de 28 anos infectada pelo HIV. Discutimos uma possível etiologia autoimune para justificar o quadro.