<![CDATA[Introduction: Intracranial tuberculoma and brain metastasis present with overlapping clinical and neuroimaging features. This distinction is critical because their diagnostic pathways and treatments differ fundamentally, and the dilemma is amplified when metastatic carcinoma and active tuberculosis coexist in the same patient. Case Description: A 60-year-old Indonesian man presented with decreased consciousness, a one-year history of chronic headache, right hemiparesis, abducens and facial nerve palsies, fever, weight loss, and long-standing left cervical and supraclavicular lymphadenopathy. Histopathology of a cervical lymph node demonstrated metastatic carcinoma without an identified primary site. Head computed tomography revealed multiple hypodense lesions with vasogenic edema, initially suggestive of metastases, whereas contrast-enhanced neck magnetic resonance imaging incidentally showed multiple enhancing intracranial lesions, including a 12.4 × 10.6 × 11.3 mm left temporal lesion, interpreted as favoring tuberculoma. Sputum examination was positive for tuberculosis despite an unremarkable chest radiograph. Antituberculosis therapy with corticosteroids and supportive neurological management was initiated, and the Glasgow Coma Scale improved from 12 to 15. Intracranial biopsy and lumbar puncture were not available. The patient was discharged on day 7 but died at home 5 days later, leaving the intracranial diagnosis unconfirmed. Conclusion: Coexisting metastatic carcinoma and sputum-positive tuberculosis create genuinely competing etiologies for enhancing brain lesions. Neither extracranial cytology nor sputum positivity can establish the nature of an intracranial lesion. Tissue or microbiological confirmation, a systematic primary-tumor workup, and multidisciplinary interpretation should be pursued whenever feasible to avoid premature diagnostic closure.]]>
