Case Presentation: Mr Z is a 54 year-old gentleman with no past medical history. He presented with chronic headache for 5 months that occurred daily, worst over the right frontal region, radiated down his neck, and was aggravated by neck movements. There was associated right ear tinnitus and hearing loss. He was evaluated 3 months ago with magnetic resonance imaging (MRI) of his brain and internal auditory meatus which was normal. Cervical spine x-ray showed early degenerative changes. He was diagnosed with migraine vs cervicogenic headache and was trialed on paracetamol, diclofenac, tramadol, cafergot, propranolol and amitriptyline. He represented due to persistent headache, progressive bilateral hearing loss, and right eye blurring of vision for 2 months. There was associated photophobia, vomiting, and weight loss of 10 kilograms. An ophthalmology review revealed right eye optic neuropathy. A chest x-ray showed diffuse reticulonodular shadowing in both lung fields. Differential diagnoses at this point included disseminated tuberculosis (TB), malignancy, and sarcoidosis. Computed-tomography (CT) scan subsequently showed a left lower lobe lung nodule, multiple smaller nodules in both lungs, enlarged intra-thoracic lymph nodes, and multiple sclerotic and lytic lesions in the bones suspicious for primary lung malignancy with nodal, pulmonary, and skeletal metastases. A repeat MRI brain showed new leptomeningeal enhancement along the cerebellum and brainstem, and new equivocal enhancement in bilateral internal auditory canals. Lumbar puncture (LP) revealed a high opening pressure, and cerebrospinal fluid (CSF) analysis showed low glucose and elevated protein levels. He was empirically commenced on anti-TB therapy after LP findings were suggestive of TB, while awaiting biopsy of the lung nodule for histological confirmation of malignancy.
Discussion: Although this patient’s headache had migrainous and cervicogenic features, the lack of response to treatment, weight loss, visual and hearing loss should trigger further investigations including repeat imaging despite an initial normal MRI. After the CT scan showed suspected malignancy, it is important to rule out other conditions such as TB that can present similarly with weight loss, lung nodules, and meningeal involvement. It is possible to have dual pathologies as TB is more common in immunocompromised hosts, and can be diagnosed synchronously with malignancy. Furthermore, determining meningeal involvement by TB or malignancy will significantly change the management and prognosis of this patient.
Conclusions: Chronic headaches are not uncommon, but physicians need to be aware of red flag symptoms that warrant further investigations. These include failure of therapy, neurological and constitutional symptoms. This case illustrates the importance of thorough investigations and avoiding cognitive biases such as anchoring and premature closing, to avoid missing curable conditions such as TB that may mimic or concomitantly present with malignancy.