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A 21-year-old man presented with fever, headache, nausea, vomiting and significant weight loss for the past 2 months. There was no history of seizure, muscle enlargement or subcutaneous nodules. Neurological examination was within normal limits. A diagnosis of meningitis was made based on history and general examination. Imaging was carried out. MRI of the brain showed a ‘starry sky’ appearance with multiple nodular enhancing lesions in supratentorial and infratentorial brain parenchyma (figures 1 and and2).2). Lesions were also observed at the cervicomedullary junction (figure 3) in a mid sagittal section of brain and cervical spine, so a further mid sagittal section of MRI of the whole spine was carried out. It showed diffusely scattered intramedullary lesions in the whole spinal cord (figure 4). Images of this type, showing diffusely and almost evenly distributed lesions in the central nervous system, are rarely seen. Imaging studies, especially MRI, are extremely important, as they aid in detecting more extensive lesions by, for example, presenting a ‘starry sky’ appearance, as occurred using brain MRI in our case. Other differential diagnoses that can present with a ‘starry sky’ appearance on neuroimaging are tuberculomas, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), microabscess, toxoplasmosis, mycotic granulomas, low-grade astrocytoma and cystic cerebral metastasis.1 2 In disseminated neurocysticercosis, symptoms are related to a space-occupying effect rather than inflammation caused by dying parasites, and in this situation, cysticidal drugs may exacerbate the syndrome of intracranial hypertension.1 3 These lesions may also be giving us a view of the central nervous system blood supply to the deepest structures through which these cysticerci would have reached there. This rare imaging finding suggests that ‘stars can be beyond the sky’, and a careful thorough imaging protocol must be followed in such cases.
The authors thank Dr Shalini Jaiswal for helping in reporting neuroimaging of the patient.
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.