title: Holmes tremor in a patient with progressive multifocal leukoencephalopathy.
abstract: BACKGROUND
  Progressive multifocal leukencephalopathy (PML) is a rare, sometimes fatal viral disease in patients with primary or secondary immunosuppression.
  
  
  METHODS
  A 57-year-old immunocompetent female with intractable Holmes tremor and elongated unique brainstem lesion reported to our hospital. The cerebrospinal fluid (CSF) screening for John Cunningham virus was negative and the diagnosis was established by brain biopsy. The course was rapidly fatal.
  
  
  CONCLUSIONS
  This atypical presentation of PML in an immunocompetent patient illustrates that diagnosis can be missed without brain biopsy.
authors.affiliation: Department of Neurosurgery, Center Hospital Luxembourg, Luxembourg City, Luxembourg.
authors.forename: Vimal Raj Nitish
authors.initials: VR
authors.lastname: Gunness
authors.affiliation: Department of Neuroradiology, Center Hospital Luxembourg, Luxembourg City, Luxembourg.
authors.forename: Georges
authors.initials: G
authors.lastname: Dooms
authors.affiliation: Department of Neurology, Hospital of Ettelbruck, Luxembourg.
authors.forename: Bernd
authors.initials: B
authors.lastname: Wauschkuhn
authors.affiliation: Trier Histopatological Center, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Feiden
authors.affiliation: Department of Neurosurgery, Center Hospital Luxembourg, Luxembourg City, Luxembourg.
authors.forename: Frank
authors.initials: F
authors.lastname: Hertel
keywords: Brainstem; Holmes tremor; JC virus; immunocompetence; progressive multifocal leukencephalopathy