‘Starry sky’ appearance on brain CT in neurocysticercal encephalitis

Abstract

A 12-year-old boy, living in a tropical area, with no medical history, presented to the emergency department for generalized seizures evolving over a period of 6 months. Intermittent moderate headaches and decreased visual acuity for 3 months were also reported. A cerebral computed tomography (CT) scan showed the presence of multiple millimetric hyperdense spots spread over the whole brain parenchyma (white matter, grey matter, basal ganglia), giving the appearance of a ‘starry sky’ (Figure 1A). Some of these hyperdensities were contained in a vesicle corresponding to a scolex (Figure 1B). There was focal white matter inflammation (Figure 1C). All of these findings allowed the diagnosis of cysticercosis encephalitis. Antiepileptic treatment associated with intravenous methylprednisolone was started for 1 week, with a decrease in the headaches and seizures. The patient was discharged with oral prednisolone, and antiepileptic and antiparasitic drugs. Cysticercosis is a parasitic infection by the larval phase of Taenia solium with possible central nervous system or other involvement. It is more frequent in tropical environments with poor hygiene conditions and pork consumption (Tale et al., 2017Tale S. Chhabria B.A. Gawalkar A.A. Banavath H.N. Bhalla A. ‘Sleeping under the starry sky’—cysticercal encephalitis.QJM Int J Med. 2017; 110: 833-834Crossref PubMed Scopus (2) Google Scholar). Cysticercosis encephalitis is a form of neurological presentation in patients with multiple cysts where there is reactive brain inflammation after the cyst dies either spontaneously or after treatment (Tale et al., 2017Tale S. Chhabria B.A. Gawalkar A.A. Banavath H.N. Bhalla A. ‘Sleeping under the starry sky’—cysticercal encephalitis.QJM Int J Med. 2017; 110: 833-834Crossref PubMed Scopus (2) Google Scholar). Neurocysticercosis can be parenchymal, intraventricular, subarachnoid, or spinal. The parenchymal localization is mainly manifested by seizures, whereas the intraventricular localization is responsible for intracranial hypertension (Garcia et al., 2014bGarcia H.H. Nash T.E. Del Brutto O.H. Clinical symptoms, diagnosis, and treatment of neurocysticercosis.Lancet Neurol. 2014; 13: 1202-1215https://doi.org/10.1016/S1474-4422(14)70094-8Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar). The starry sky appearance on brain imaging is found in the case of numerous calcified neurocysticercosis lesions and testifies to a high parasite load. Treatment should initially include corticosteroid therapy and avoid antiparasitic treatment, which may exacerbate the inflammatory response and increase symptoms (Garcia et al., 2014aGarcia H.H. Gonzales I. Lescano A.G. Bustos J.A. Pretell E.J. Saavedra H. et al.Enhanced steroid dosing reduces seizures during antiparasitic treatment for cysticercosis and early after.Epilepsia. 2014; 55: 1452-1459https://doi.org/10.1111/epi.12739Crossref PubMed Scopus (40) Google Scholar).