An 11-year-old boy presented to the emergency department with a history of fever for one week, followed by headache, vomiting, and left eye squint for the past three weeks. He also had three episodes of generalized seizures. His father worked as a farmer. He did not report systemic symptoms or recent exposure to infection, pets, or domestic animals. There was no history of consumption of raw milk or pork, recent travel, or recurrent infections.

On examination, his heart rate was 67, and his blood pressure was 135/95 mm Hg. He had a few palpable, discrete non-tender subcutaneous nodules <1 cm distributed over the abdominal wall, axilla, and infrascapular area ( Fig. 39.1A ). Neurological examination showed diminished sensorium. He was conscious but not oriented to time, place, and person, with incoherent speech. There was left eye esotropia due to left sixth cranial nerve and seventh cranial nerve upper motor neuron palsies. He had brisk deep tendon reflexes, extensor plantar responses, meningeal signs, and bilateral papilledema. Bradycardia, hypertension, and papilledema raised concern for increased intracranial pressure (ICP) and he was treated with head elevation, sedation, and antiseizure medications.

Head CT showed tiny calcified lesions distributed over both cerebral hemispheres with surrounding edema. Contrast-enhanced brain MRI showed multiple well-defined, 1 to 5 mm, “cyst with dot” ring-enhancing lesions throughout the cerebral hemispheres, deep gray nuclei, brainstem, and cerebellum ( Figs. 39.1 and 39.2 ).

Disseminated cysticercosis. (A) Clinical photograph showing subcutaneous nodules over anterior abdominal wall and right flank ( arrows ). (B and C) Neurocysticercosis. Brain MRI, axial T1, shows multiple punctate hypointense lesions throughout the cerebral cortex and deep gray matter.

Neurocysticercosis. Brain MRI, (A and B) Axial T2, (C) FLAIR, and (D) postcontrast T1 show multifocal “cyst with dot” enhancement, calcification, and perilesional edema ( arrows ). FLAIR , Fluid-attenuated inversion recovery.

Chest radiograph, gastric aspirate for acid-fast bacilli, and Mantoux test were negative. Serology was negative for HIV and strongly positive for cysticercosis. Ultrasound of subcutaneous nodules showed hypoechoic lesions with eccentric hyperechoic nodules embedded in abdominal wall muscles.

Fever and increased intracranial pressure (ICP) can be seen with cerebral infection.

Disseminated cysticercosis can present with cerebral, ocular and soft tissue lesions.

Tubercular meningitis, disseminated or miliary CNS tuberculosis (TB) can be considered due to meningeal signs. Ocular examination may show choroidal tubercles.

Bacterial infections can develop brain abscesses and purulent empyemas.

In immunocompromised patients, invasive fungal infections include aspergillosis or mucormycosis.

Toxoplasmosis and brucellosis can also involve the central nervous system.