When Infection Masquerades as Metastasis: Tuberculous Spondylodiscitis with Fibrous Dysplasia and Capillary Hemangioma in a Patient with Newly Diagnosed Hepatic Mass

ABSTRACT: Tuberculous spondylodiscitis can closely mimic spinal metastasis, particularly in patients with coexisting malignancy risk factors and atypical imaging findings. We report a diagnostically challenging case of a 70-year-old male with chronic hepatitis B infection who presented with progressive midback pain and was found to have a hypervascular hepatic mass with elevated serum alpha-fetoprotein levels, raising strong suspicion for hepatocellular carcinoma with vertebral metastasis. Magnetic resonance imaging demonstrated destructive D10-D11 spondylodiscitis with posterior element involvement and epidural extension, while contrast-enhanced computed tomography revealed a large enhancing hepatic lesion with washout characteristics suggestive of malignancy. The extensive vertebral involvement and concurrent liver lesion created significant diagnostic uncertainty. Histopathological examination following transpedicular biopsy demonstrated fibrous dysplasia and capillary hemangioma without evidence of malignancy. Subsequent Xpert MTB/RIF assay confirmed Mycobacterium tuberculosis infection. The patient underwent posterior spinal stabilization followed by initiation of antitubercular therapy, with subsequent clinical improvement. This case highlights the potential for diagnostic anchoring toward metastatic disease in patients with concurrent visceral lesions and emphasizes the importance of maintaining suspicion for spinal tuberculosis, particularly in endemic regions. Coexisting benign vertebral lesions such as fibrous dysplasia and capillary hemangioma may further complicate interpretation by mimicking aggressive neoplastic involvement. Histopathological and microbiological confirmation remain essential for establishing the correct diagnosis and guiding management.