Complex Case of Brain Tumor and TB Highlights Diagnostic Challenges

In an intricate medical case that underscores the complexities of neurosurgical diagnosis, Dr. Gurneet Singh Sawhney, a senior consultant in neurosurgery at Fortis Hospital, navigated a challenging scenario involving a patient named Anil, who presented with alarming symptoms including balance issues, blurred vision, and robotic speech. Initial assessments suggested a brainstem tumor, leading to significant medical interventions. However, the surprising outcome of a simultaneous diagnosis of tuberculosis (TB) in the brainstem added layers of complexity to Anil's case.

Anil arrived at Dr. Sawhney's clinic in Navi Mumbai on a busy Monday, accompanied by his wife. The couple was visibly distressed; Anil had been unable to work for weeks due to his deteriorating condition. A prior MRI had indicated a large tumor in the pons, a critical area of the brainstem responsible for vital bodily functions. The first hospital he consulted deemed the surgery too risky, leaving Anil to seek further opinions in a state of uncertainty. Dr. Sawhney noted, "I saw classic signs of a pontine lesion: abnormal eye movements, slurred speech, and unsteady gait, but the MRI also revealed unexplained cerebellar inflammation and hydrocephalus. Something didn’t quite add up."

The decision was made to conduct a stereotactic biopsy, a delicate procedure that requires the patient to remain awake during the operation. As the procedure progressed, Anil unexpectedly fell asleep, a sign that the neurosurgeon interpreted as reaching the reticular activating system, which governs consciousness. This incident not only highlighted the intricacies of the surgical procedure but also served as a pivotal moment in the diagnosis. After the biopsy, the results revealed the presence of TB in the brainstem, a rare manifestation of the disease. Dr. Sawhney remarked, "I’ve seen TB affect almost every part of the body — except maybe tooth enamel — but the brainstem? That’s extremely rare."

Following the diagnosis, the treatment approach shifted dramatically. Anil initiated aggressive treatment for tuberculosis while the tumor was managed conservatively. Initially, he showed signs of improvement; however, complications arose as he became drowsy again, necessitating further interventions. A follow-up MRI indicated worsening hydrocephalus, prompting Dr. Sawhney to perform a ventriculoperitoneal (VP) shunt to alleviate the pressure caused by fluid buildup. The procedure yielded immediate relief, and Anil's recovery trajectory improved markedly thereafter.

The case illustrates the importance of considering multiple potential diagnoses, particularly in complex neurosurgical conditions. Dr. Sawhney concluded, "In medical school, we’re taught to look for one unifying diagnosis. But Anil had two: a tumor causing pressure and TB causing inflammation. Medicine isn’t always about finding a neat, singular answer. Sometimes, your gut tells you there’s more to the story."

Anil's journey serves as a reminder of the pivotal role that thorough investigation plays in medical practice and the importance of remaining vigilant in the face of diagnostic uncertainty. As Dr. Sawhney reflected on this experience, he emphasized the need for healthcare professionals to trust their instincts and remain open to the possibility of multiple underlying conditions.