The Cancer That Vanished: A Case of Tuberculous Spondylitis Mimicking Metastatic Disease in a High-Stakes Diagnosis

Skeletal tuberculosis remains a great clinical mimicker, often resembling metastatic malignancy on imaging. Prompt and accurate diagnosis is critical to prevent irreversible neurological damage and iatrogenic harm. We describe a diagnostically challenging case involving a 39-year-old previously healthy woman from Zimbabwe who presented with subacute thoracic back pain and bilateral lower limb sensory changes. MRI demonstrated destructive vertebral lesions with spinal cord compression and widespread lymphadenopathy, strongly suggestive of metastatic disease. Further imaging, including contrast-enhanced CT and positron emission tomography (PET)-CT, supported the metastatic pattern but failed to identify a primary malignancy. The patient underwent spinal radiotherapy for presumed metastatic cord compression without clinical improvement. A subsequent CT-guided biopsy revealed caseating granulomatous inflammation and acid-fast bacilli, confirming spinal tuberculosis. Following initiation of standard anti-tubercular therapy, the patient showed marked clinical improvement, including complete resolution of pain and partial neurological recovery. Unfortunately, some sensory impairment persisted due to radiation-induced myelitis - an avoidable complication of premature treatment. This case signifies the importance of maintaining a high index of suspicion for spinal tuberculosis, especially in patients from endemic regions, even in the absence of classic systemic features. It is especially relevant to acute medicine, where clinicians are often the first to assess patients with spinal pain and red flag neurological signs. It highlights the need for histological confirmation before initiating oncologic therapies in uncertain diagnoses. Early tissue diagnosis, guided by WHO and national TB protocols, is essential to avoid misdiagnosis and ensure appropriate management.