Glioblastoma: The camouflaged presentation

Abstract

Case historyA 56-year-old gentleman presented via telephone triage with a 3-week history of morning headache. He had no significant comorbidities. He described a unilateral aching pain extending from his right eye to the occiput. The GP also elicited poor sleep, apnoeic episodes and snoring. Obstructive sleep apnoea was the provisional diagnosis and the patient was booked for review with a GP registrar.At review the pain was noted to be worse in the mornings and associated with increased fatigue. The patient commented: 'I can fall asleep at a moment's notice'. His partner reported a decline in mood and more aggressive behaviour. There were no signs of focal neurology, no nausea or vomiting and examination was unremarkable. A sleep apnoea-focused history was taken and the patient reassured that the headache was benign. Safety netting was documented as, 'worsening advice given'. The patient sought further advice over the phone 10 days later and reported worsening pain and mild photophobia. The diagnosis of sleep apnoea was reaffirmed and the patient was advised to seek help if symptoms deteriorated, but specific safety netting advice was not documented.After a further two weeks the patient presented with vomiting, confusion and drowsiness. Nystagmus was noted and he was sent to the emergency department for a suspected space-occupying lesion. A computerised tomography scan showed a right frontal tumour, in keeping with a glioblastoma and the patient was commenced on dexamethasone, providing significant symptomatic relief. The diagnosis was confirmed by a subsequent magnetic resonance imaging and biopsy, following which chemotherapy and radiotherapy were organised.