Starry Sky on MRI brain: Unusually observed in a pediatric case of Japanese Encephalitis

A 13-year-old girl presented with fever, nausea and projectile vomiting and altered sensorium. On physical examination, the meningeal signs were presented without focal neurological deficits and Grade Ⅱ papilledema was presented on fundus examination. The patient was found to be positive for Japanese encephalitis virus in cerebrospinal fluid. Focal neurological deficit in the form of right hemiparesis was noticed at day 6 of hospitalisation. Multiple lesions with minimal enhancement with perilesional edema were observed in cerebral cortex in contrast with enhanced magnetic resonance imaging of the brain, giving rise to starry sky appearance. No tests for neurotuberculosis were found positive. Serum IgG enzyme-linked immunosorbent assay test was negative for Cysticercosis, but magnetic resonance spectroscopy was suggestive of cysticercal meningitis. During treatment, she had intermittent episodes of nausea and vomiting with waxing and waning sensorium. Subsequently, it was planned to start Albendazole after steroids coverage and anticonvulsants but the patient did not improve and succumbed to her illness.