Cysticercal Encephalitis Presenting with a “Starry Sky” Appearance on Neuroimaging

Abstract

A lady in her early forties was brought to our hospital in an unconscious state with history of generalized tonic-clonic seizures for last 6 h. She had multiple episodes of seizures in last 4 months, but did not receive any treatment. Relatives also gave a history of fever, headache, and vomiting for last 1 week. Her seizures were controlled with intravenous lorazepam and valproate. Clinical examination revealed a delirious patient with bilateral papilledema, brisk deep tendon reflexes, and extensor plantars. She had aspirated and had bilateral coarse crepitations on chest auscultation. Computed tomography (CT) of brain showed multiple small hyperdense calcific lesions extending throughout both the cerebral hemispheres leading to a “starry sky” appearance, suggestive of cysticercal encephalitis. The patient succumbed to progressive aspiration pneumonitis on the 6^th day after hospitalization.

SUMMARY OF CASE

A lady in her early forties was brought to our hospital in an unconscious state with history of generalized tonic-clonic seizures for last 6 h. She had multiple episodes of seizures in last 4 months, but did not receive any treatment. Relatives also gave a history of fever, headache, and vomiting for last 1 week. Her seizures were controlled with intravenous lorazepam and valproate. Clinical examination revealed a delirious patient with bilaterally normal size, reacting pupils, and intact oculocephalic reflex. Ophthalmoscopy showed bilateral papilledema. She had a flexor limb response to painful stimulus. Her deep tendon reflexes were brisk and plantars were bilateral extensor. She had aspirated and had bilateral coarse crepitations on chest auscultation. Her oxygen saturation was 92% on oxygen. Urgent computed tomography (CT) of brain was done which showed multiple small hyperdense calcific lesions extending throughout both the cerebral hemispheres leading to a “starry sky” appearance [Figure 1a–d]. The lesions were denser at gray-white matter junction. In a country like India, which is endemic for neurocysticercosis, this radiologic appearance is characteristic for neurocysticercosis. As our patient had features of raised intracranial pressure, a diagnosis of cysticercal encephalitis was made. Despite giving the best medical and supportive care, the patient succumbed to progressive aspiration pneumonitis on the 6^th day after hospitalization.

Figure 1.

[a,b,c,d] Plain computed tomography (CT) of brain showing multiple intraparenchymal calcific and cystic lesions of neurocysticercosis, resulting in a “starry sky” appearance

Neurocysticercosis, caused by Taenia solium, is the commonest parasitic disease of the nervous system.[1] It is more common in rural population due to poor sanitation and low socio-economic status. Cysticercal encephalitis is an unusual presentation in patients with multiple intracranial cysts, in whom inflammation of brain parenchyma occurs due to toxic reaction to cysticercal antigens which are released after the death of cysts either spontaneously or due to cysticidal therapy. Starry sky appearance in neuroimaging is seen in patients with numerous neurocysticercosis lesions with calcifications. A similar case was reported by Kishore et al. in a patient without seizures.[2] Radiological appearance similar to our case has been mentioned in a case report by Sodhi et al.[3] Such presentation of neurocysticerosis occurs in patients with a heavy parasitic load.