RESUMO
BACKGROUND: Lower urinary tract symptoms (LUTS) are common in women with multiple sclerosis. OBJECTIVE: To investigate the impact of LUTS on pelvic floor muscle contraction, sexual function, and quality of life in women with multiple sclerosis. METHODS: Thirty-nine women with relapsing-remitting multiple sclerosis were enrolled in this study. Participants were divided into the presence or not of LUTS. Assessments involved the Expanded Disability Status Scale score, the NEW PERFECT scheme, the Female Sexual Function Index, and the Qualiveen Questionnaire. Statistical procedures involved Student t-tests, chi-squared, and regression analyses (R2). RESULTS: Nineteen women (48.7%) presented LUTS. Women with LUTS were in a more advanced stage of multiple sclerosis (p = .029), presented weaker pelvic muscle contraction (p = .009), less sexual function satisfaction (p = .018), and more limitations in the quality of life (p = .001) than women without LUTS. Regression analyses pointed out that the quality of life and sexual function of women with multiple sclerosis are affected by intercourse pain (R2 = 12.9) and perineal contraction force (R2 = 19.2). CONCLUSION: LUTS affects pelvic floor muscle contraction, sexual function, and quality of life in women with multiple sclerosis. A multi-professional rehabilitation team should assist women with multiple sclerosis, taking special care of LUTS.
Assuntos
Sintomas do Trato Urinário Inferior , Esclerose Múltipla , Feminino , Humanos , Estudos Transversais , Qualidade de Vida , Pelve , Inquéritos e QuestionáriosRESUMO
RATIONALE: Teriflunomide is an inhibitor of pyrimidine synthesis available as a first-line treatment for relapsing-remitting multiple sclerosis. Drug-induced liver damage is a relevant problem in clinical practice, representing a frequent cause of treatment discontinuation. This case report describes the occurrence of liver injury, with a 33.7-fold increase in the upper limit of normality of the liver enzyme alanine aminotransferase during treatment with teriflunomide 14âmg. PATIENT CONCERN: A 44-year-old woman receiving teriflunomide 14âmg for the treatment of multiple sclerosis presented symptoms suggestive of liver dysfunction 54âdays after starting treatment. The patient had no history of using disease-modifying therapy, neither previous liver disease nor other comorbidities. DIAGNOSTICS: The suggested diagnosis was drug-induced liver injury, classified as hepatocellular. Other possible hepatic and autoimmune etiologies were ruled out. INTERVENTIONS: Replacement of teriflunomide treatment with glatiramer acetate and follow-up of the disease. OUTCOMES: Signs and symptoms regressed after treatment with teriflunomide 14âmg was discontinued, with normalization of liver enzyme activity in â¼5âmonths. The causality assessment of the adverse drug reaction was determined by the Naranjo scaling system, resulting in probable, with a final score of 7. CONCLUSIONS: Teriflunomide-induced liver injury in patients with multiple sclerosis is a serious adverse reaction. The report of this case contributes to updating knowledge about the safety aspects of treatment with teriflunomide and planning of monitoring strategies and patient risk management.
Assuntos
Anti-Inflamatórios não Esteroides/efeitos adversos , Doença Hepática Induzida por Substâncias e Drogas , Crotonatos/efeitos adversos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Hidroxibutiratos/efeitos adversos , Esclerose Múltipla Recidivante-Remitente , Esclerose Múltipla/tratamento farmacológico , Nitrilas/efeitos adversos , Toluidinas/efeitos adversos , Adulto , Anti-Inflamatórios não Esteroides/uso terapêutico , Crotonatos/uso terapêutico , Feminino , Humanos , Hidroxibutiratos/uso terapêutico , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológico , Nitrilas/uso terapêutico , Toluidinas/uso terapêutico , Resultado do TratamentoRESUMO
Introdução: A esclerose múltipla (EM) é a mais comum das doenças desmielinizantes, caracterizada pela localização de múltiplas placas de desmielinização na substância branca encefálica e medular. A mielopatia associada ao HTLV-I (HAM/TSP) é uma doença neurodegenerativa progressiva cuja resposta imune é exacerbada. Objetivo: Avaliar o efeito da eletroterapia na musculatura do assoalho pélvico (MAP) sobre os sintomas hiperatividade detrusora em mulheres com EM e HTLV-1. Métodos: Ensaio clínico randomizado e controlado com 4 meses de acompanhamento, no qual 20 mulheres em estágio moderado de EM ou HTLV1 submetidas a um programa de treinamento da MAP associado ou não à eletroterapia. As variáveis analisadas foram: sintomas de bexiga hiperativa (BH) pelo questionário validado OAB v8, contração perineal pelo esquema PERFECT e índice de qualidade de vida por meio do questionário Qualiveen. Divididas em dois grupos, grupo controle (G2) e grupo tratamento (G1) que foi submetido a um protocolo de treinamento da MAP, realizado duas vezes por semana por 20 sessões e após este período de tempo todas as mulheres foram reavaliadas. Resultados: Sob-homogeneidade inicial observada nas variáveis pessoais e clínicas, o protocolo a que o grupo tratamento (G1) foi submetido resultou na melhora da contração voluntária (p ≤ 0,001), teste de esforço (p ≤ 0,001), reflexo cutâneo-anal (p ≤ 0,001), força de contração (p ≤ 0,001), sustentação (p ≤ 0,001), contrações rápidas (p ≤ 0,001), contrações lentas (p ≤ 0,001) e nos sintomas de bexiga hiperativa (p ≤ 0,001), em relação à comparação inicial. Os resultados comprovam a eficácia de exercícios de fortalecimento da MAP acompanhados por um fisioterapeuta e o uso de correntes eletroterápicas de média frequência para o tratamento da BH na Esclerose Múltipla e na mielopatia associada ao HTLV-1. Conclusão: O protocolo de eletroestimulação mostrou-se benéfico em pacientes com EM e HTLV-1, promovendo melhora da BH e grau de contração perineal. (AU)
Introduction: Multiple sclerosis (MS) is the most common of demyelinating diseases, characterized by multiple demyelination plaques in white brain and spinal cord. Myelopathy associated with HTLV-I (HAM/TSP) is a progressive neurodegenerative disease whose immune response is exacerbated. Objective: To evaluate the effect of electrotherapy in the pelvic floor muscles (MAP) on the symptoms of overactive bladder in women with MS and HTLV-1. Methods: Randomized, controlled clinical trial with 4 months of follow-up, in which 20 women in the moderate stage of MS or HTLV-1 performed a MAP training program associated or not with electrotherapy. The variables analyzed were: overactive bladder, validated OAB v8 questionnaire, perineal contraction by PERFECT scheme, and quality of life index using the Qualiveen questionnaire. Divided into two groups, control group (G2) and treatment group (G1) who underwent a MAP training protocol, performed twice a week for 20 sessions and after this time period all the women were re-evaluated. Results: Under initial homogeneity observed in the personal and clinical variables, the protocol to which the treatment group (G1) was submitted resulted in the improvement of the voluntary contraction (p = 0.001), stress test (p ≤ 0.001), pudendo-anal reflex (p ≤ 0.001), contraction force (p ≤ 0.001), sustentation (p ≤ 0.001), rapid contractions (p ≤ 0.001), slow contractions (p ≤ 0.001) and symptoms of overactive bladder (p ≤ 0.001) compared to the initial controle. The results demonstrate the effectiveness of MAP strengthening exercises followed by a physiotherapist and the use of medium frequency electrotherapy currents for the treatment of BH in multiple sclerosis and HTLV-1 associated myelopathy. Conclusion: The protocol of electrostimulation was beneficial in patients with MS and HTLV-1, promoting improvement of overactive bladder and degree of perineal contraction. (AU)
Assuntos
Humanos , Feminino , Doenças da Medula Espinal , Terapia por Estimulação Elétrica , Diafragma da Pelve , Esclerose Múltipla , Modalidades de Fisioterapia , Ensaio Clínico Controlado Aleatório , Bexiga Urinária HiperativaRESUMO
OBJECTIVE: The aim of the study was to investigate the effects of two pelvic floor exercise programs on lower urinary tract symptoms and quality of life in participants with multiple sclerosis. DESIGN: This is a prospective, single-blind, clinical trial. SETTINGS: The study used a community rehabilitation program within a large metropolitan health service. PARTICIPANTS: Thirty women in moderate stage of multiple sclerosis were referred for outpatient rehabilitation. INTERVENTIONS: In a period of 6 mos, participants underwent a pelvic floor exercise program, associated or not with vaginal electrotherapy. MAIN OUTCOMES: The main outcomes are overactive bladder, perineal contraction, and quality of life. RESULTS: The findings showed benefits of both programs on overactive bladder and quality of life. Participants undergoing exercise plus electrotherapy presented greater improvement on contraction of the perineal musculature and quality of life. CONCLUSIONS: Six months of exercise provided benefits on lower urinary tract symptoms and quality of life in women with multiple sclerosis. Electrical stimulation potentiated the improvement on perineal musculature and quality of life. This trial was registered prospectively with the Clinical Trials Register, ID: BR-287q65 (http://www.ensaiosclinicos.gov.br/rg/RBR-287q65/).
Assuntos
Terapia por Exercício/métodos , Sintomas do Trato Urinário Inferior/terapia , Esclerose Múltipla/terapia , Diafragma da Pelve/fisiologia , Transtornos Urinários/terapia , Adulto , Feminino , Humanos , Sintomas do Trato Urinário Inferior/etiologia , Pessoa de Meia-Idade , Esclerose Múltipla/complicações , Estudos Prospectivos , Qualidade de Vida , Método Simples-CegoRESUMO
OBJECTIVE: The aim of the study was to investigate the effects of a 6-mo exercise program on cognition and mobility in participants with multiple sclerosis. DESIGN: This is a prospective, single-blind, controlled clinical trial. SETTING: A community rehabilitation program within a large metropolitan health service. PARTICIPANTS: Twenty-eight patients with multiple sclerosis were referred for outpatient rehabilitation. INTERVENTIONS: Participants were allocated to one of two groups and undertook a cognitive-motor exercise program or monitoring (control group). MAIN OUTCOME MEASURES: Cognition and mobility were the main outcome measures. Cognition was evaluated using the Mini-Mental State Examination and the Frontal Assessment Battery. Mobility was assessed with the Timed Get Up and Go test, applied with and without dual task distractors. RESULTS: The findings showed benefits provided by exercise on cognition and mobility. Differently, participants of the control group did not have significant changes in cognition scores after 6 mos of follow-up and had a worse performance in mobility tests. CONCLUSION: Six months of exercise provided benefits to cognition and mobility in adults with multiple sclerosis. This trial was registered prospectively with the Brazilian Clinical Trials Register, ID: RBR-9gh4km (http://www.ensaiosclinicos.gov.br/rg/?q=RBR-9gh4km). TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the physical and cognitive decline in multiple sclerosis; (2) Identify the importance of exercise on cognition and mobility in patients with multiple sclerosis; and (3) Appreciate the potential benefit of dual tasking in the rehabilitation of individuals with multiple sclerosis.Level: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Assuntos
Cognição/fisiologia , Terapia por Exercício , Atividade Motora/fisiologia , Esclerose Múltipla/psicologia , Esclerose Múltipla/reabilitação , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/fisiopatologia , Estudos Prospectivos , Método Simples-Cego , Análise e Desempenho de Tarefas , Adulto JovemRESUMO
OBJECTIVE: The objective of this study was to investigate the effects of two programs for strengthening the pelvic floor on the urinary incontinence of patients with multiple sclerosis (MS). DESIGN: This is a prospective study of the clinical trial type, monitored for 6 mos, in which 24 women in the moderate stage of MS participated in a program of exercises for strengthening the pelvic floor-associated (experimental group) or not (control group) with electrotherapy. The variables analyzed were as follows: quality-of-life, overactivity of the bladder, perineal contraction, and level of anxiety and depression. The statistical procedures involved multivariate analyses of repeated measurements, with a significance of 5%. RESULTS: Initial homogeneity being observed in the anthropometric and clinical variables, both protocols resulted in improvements in quality-of-life (P = 0.001), overactive bladder (P = 0.001), perineal contraction (P = 0.004), and level of anxiety (P = 0.001) and depression (P = 0.001), in relation to the initial comparison. The association of electrotherapy with strengthening exercises increased the improvement of the patients regarding overactive bladder (P = 0.039) and perineal contraction (P = 0.001), in comparison with the control group. CONCLUSIONS: The results reinforce the benefit of exercises for strengthening the musculature of the pelvic floor in women with overactive bladder in MS and demonstrate a potential of the action when associated with electrotherapy. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES:: Upon completion of this article, the reader should be able to: (1) Identify common dysfunctions of the lower urinary tract in women with multiple sclerosis; (2) Discuss the relationship between quality-of-life, level of anxiety and depression, degree of perineal contraction, and overactive bladder; and (3) Recognize the benefits promoted by physical therapy for strengthening the pelvic floor in patients with multiple sclerosis. LEVEL: Advanced ACCREDITATION: : The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.
Assuntos
Terapia por Estimulação Elétrica , Terapia por Exercício , Esclerose Múltipla/fisiopatologia , Diafragma da Pelve/fisiopatologia , Incontinência Urinária/reabilitação , Adulto , Ansiedade/terapia , Feminino , Humanos , Contração Muscular/fisiologia , Força Muscular/fisiologia , Estudos Prospectivos , Qualidade de Vida , Incontinência Urinária/fisiopatologia , Incontinência Urinária/psicologiaRESUMO
Multiple sclerosis (MS) is a chronic, neurological, immune-mediated disease that can worsen in the postpartum period. There is no consensus on the use of immunoglobulin for prevention of disease relapses after delivery. We have shown that the controversial beneficial effect of immunoglobulin given immediately after birth could not be observed in patients with MS.
Assuntos
Imunoglobulinas Intravenosas/uso terapêutico , Mães , Esclerose Múltipla Recidivante-Remitente/prevenção & controle , Esclerose Múltipla/tratamento farmacológico , Período Pós-Parto/efeitos dos fármacos , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Imunoglobulinas Intravenosas/farmacologia , Esclerose Múltipla/complicações , Esclerose Múltipla/fisiopatologia , Gravidez , Complicações na Gravidez/tratamento farmacológico , Complicações na Gravidez/imunologia , Resultado da Gravidez , Transtornos Puerperais/prevenção & controle , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: Natalizumab is a new and efficient treatment for multiple sclerosis (MS). The risk of developing progressive multifocal leukoencephalopathy (PML) during the use of this drug has created the need for better comprehension of JC virus (JCV) infection. The objective of the present study was to assess the prevalence of JCV-DNA in Brazilian patients using natalizumab. METHOD: Qualitative detection of the JCV in the serum was performed with real-time polymerase chain reaction (PCR). RESULTS: In a group of 168 patients with MS who were undergoing treatment with natalizumab, JCV-DNA was detectable in 86 (51.2%) patients. DISCUSSION: Data on JCV-DNA in Brazil add to the worldwide assessment of the prevalence of the JCV in MS patients requiring treatment with natalizumab.
Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , DNA Viral/análise , Vírus JC/genética , Leucoencefalopatia Multifocal Progressiva/induzido quimicamente , Esclerose Múltipla/tratamento farmacológico , Adulto , Brasil/epidemiologia , Feminino , Humanos , Vírus JC/imunologia , Leucoencefalopatia Multifocal Progressiva/epidemiologia , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/virologia , Natalizumab , Reação em Cadeia da Polimerase em Tempo Real , Fatores de RiscoRESUMO
Objective Natalizumab is a new and efficient treatment for multiple sclerosis (MS). The risk of developing progressive multifocal leukoencephalopathy (PML) during the use of this drug has created the need for better comprehension of JC virus (JCV) infection. The objective of the present study was to assess the prevalence of JCV-DNA in Brazilian patients using natalizumab. Method Qualitative detection of the JCV in the serum was performed with real-time polymerase chain reaction (PCR). Results In a group of 168 patients with MS who were undergoing treatment with natalizumab, JCV-DNA was detectable in 86 (51.2%) patients. Discussion Data on JCV-DNA in Brazil add to the worldwide assessment of the prevalence of the JCV in MS patients requiring treatment with natalizumab. .
Objetivo Natalizumabe é um tratamento novo e eficaz para esclerose múltipla (EM). O risco constatado de desenvolver leucoencefalopatia multifocal progressiva (LEMP) durante o uso desta droga criou a necessidade de melhor estudar a infecção pelo vírus JC (JCV). O objetivo do presente estudo foi avaliar a prevalência de DNA-JCV em paciente brasileiros usando natalizumabe. Método Detecção qualitativa de JCV no soro foi realizada através de reação em cadeia por polimerase (PCR) em tempo real. Resultados DNA-JCV foi detectado em 86 pacientes (51,2%) de um grupo de 168 pessoas com EM recebendo tratamento com natalizumabe,). Discussão Dados do DNA-JCV no Brasil complementam as avaliações mundiais sobre a prevalência de JCV em pacientes com EM que necessitam tratamento natalizumabe. .
Assuntos
Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Anticorpos Monoclonais Humanizados/efeitos adversos , DNA Viral/análise , Vírus JC/genética , Leucoencefalopatia Multifocal Progressiva/induzido quimicamente , Esclerose Múltipla/tratamento farmacológico , Brasil/epidemiologia , Vírus JC/imunologia , Leucoencefalopatia Multifocal Progressiva/epidemiologia , Esclerose Múltipla/virologia , Reação em Cadeia da Polimerase em Tempo Real , Fatores de RiscoRESUMO
OBJECTIVE: To assess the prevalence and the profile of adverse events (AE) of natalizumab in patients with multiple sclerosis (MS). METHODS: Data collection from neurologists attending to patients with MS at specialized units in Brazil. RESULTS: Data from 103 patients attending the infusion centers of 16 MS units in 9 Brazilian states were included in the study. The total number of infusions was 1,042. Seventy-nine patients (76.7%) did not present any AE. Twenty-four patients (23.3%) presented only mild AE. There were three major AE, including two deaths. These three occurrences, although not necessarily being drug-related, must be taken into consideration. CONCLUSION: The profile of AEs for natalizumab shows that 97% of patients have none or only mild AE. However, still due to safety worries, the use of this medication should be restricted to MS units under the care of specialized neurologists.
Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Esclerose Múltipla/tratamento farmacológico , Adolescente , Adulto , Brasil , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Natalizumab , Estudos Retrospectivos , Adulto JovemRESUMO
Assuntos
Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Anticorpos Monoclonais Humanizados/efeitos adversos , Esclerose Múltipla/tratamento farmacológico , Brasil , Estudos RetrospectivosRESUMO
The epidemiological, clinical and laboratory features of 13 cases of neuroparacoccidioidomycosis (NPCM) were analysed. All patients were men, with a mean age of 41.6 years. The lungs were involved in 11 cases (84.6%) and only two cases had mycosis limited to the central nervous system. Co-morbidity was observed in four patients (malignant neoplasm in three and diabetes mellitus in one). The most frequent neurological manifestations were paresis (eight cases), headache (five cases) and gait disturbance (four cases). Neuroimaging diagnosis showed a predominance of multiple round lesions with ring enhancement following contrast medium injection. Lesions were seen in the brain hemispheres (nine cases), thalamus (nine cases), cerebellum (four cases), brainstem (four cases) and spinal cord (four cases). Most cases responded well to therapy. Lesions with enhancement following contrast medium injection persisted in four patients for a period of 6 months to 8 years. These findings emphasize the importance of considering NPCM in the differential diagnosis of brain and spinal cord lesions in endemic areas of paracoccidioidomycosis.
Assuntos
Infecções Fúngicas do Sistema Nervoso Central/diagnóstico , Paracoccidioidomicose/diagnóstico , Adulto , Antifúngicos/uso terapêutico , Infecções Fúngicas do Sistema Nervoso Central/complicações , Infecções Fúngicas do Sistema Nervoso Central/tratamento farmacológico , Seguimentos , Transtornos Neurológicos da Marcha/microbiologia , Cefaleia/microbiologia , Humanos , Masculino , Pessoa de Meia-Idade , Paracoccidioidomicose/complicações , Paracoccidioidomicose/tratamento farmacológico , Paresia/microbiologiaRESUMO
O envolvimento do sistema nervoso central na paracoccidioidomicose tem sido pouco descrito na literatura, sendo rara sua apresentação sob a forma meníngea. Descreve-se o caso de um paciente de 23 anos que desenvolveu meningite paracoccidioidomicótica comprovada pela positividade do fungo na pesquisa direta e cultura do líquido cefaloraquidiano. Discute-se a apresentação da forma meníngea da paracoccidioidomicose, seu diagnóstico laboratorial e neurorradiológico. Destaca-se a importância da investigação rotineira do fungo
Assuntos
Humanos , Masculino , Adulto , Meningite Fúngica , Paracoccidioides , Paracoccidioidomicose , Meningite Fúngica , Paracoccidioidomicose , Tomografia Computadorizada por Raios XRESUMO
The involvement of the central nervous system in paracoccidioidomycosis and its meningeal form of clinical presentation have rarely been described. This is a case report of a 23 years old man who developed paracoccidioidomycosis meningitis achieved by fungus' presence in direct research and culture of cerebrospinal fluid. The meningeal form of paracoccidioidomycosis, its laboratorial and imaging diagnostic are discussed, and the importance of the routine investigation of the fungus is emphasized.
Assuntos
Meningite Fúngica/diagnóstico , Paracoccidioides/isolamento & purificação , Paracoccidioidomicose/diagnóstico , Adulto , Humanos , Masculino , Meningite Fúngica/líquido cefalorraquidiano , Meningite Fúngica/microbiologia , Paracoccidioidomicose/líquido cefalorraquidiano , Paracoccidioidomicose/microbiologia , Tomografia Computadorizada por Raios XRESUMO
A miastenia grave (MG) é uma doença auto-imune, caracterizada pela alteraçäo da transmissäo neuromuscular, que pode associar-se a outras patologias auto-imunes, sendo as doenças tireoidianas uma das suas mais freqüentes associaçöes. Descreve-se dois casos de pacientes que desenvolveram MG de forma generalizada associada à doença de Graves. Discute-se a etiopatogenia, a apresentaçäo e o diagnóstico clínico-laboratorial dessa associaçäo, assim como seu tratamento clínico e cirúrgico. Destaca-se a importância do diagnóstico precoce da doença tireoidiana nos pacientes com miastenia grave
Assuntos
Humanos , Feminino , Adulto , Doença de Graves/cirurgia , Doença de Graves/diagnóstico , Doença de Graves/etiologia , Doença de Graves/terapia , Miastenia GravisRESUMO
Paciente masculino, 73 anos, do interior de Mato Grosso do Sul, com diagnostico inicial de sinusite, evoluiu em 3 dias para quadro de hipertensao intracraniana severa. Transferido para o servico de neurologia, os exames evidenciaram leucemia linfocitica e indicaram ainda processo inflamatorio expansivo como abscesso ou tumor (exame do liquido e tomografia). Instituiu-se Ceftriaxone e Decadron. Foi feita nova puncao lombar, injetou-se metotrexate considerando possivel infiltracao leucemica. No liquido observou-se formas flagelares de T. cruzi. Iniciou-se benzonidazol. Apos 4 dias o liquor apresentou formas fracionadas de tripomastigotas. O nivel de proteinas se estabilizou em 27 por cento. Cessou a sintomatologia da hipertensao. Tomografia e ressonancia magnetica posterior mostraram importante reducao da formacao tumoral observada anteriormente. Houve melhora das condicoes clinicas do paciente