Our case, 67-year-old man, chronic smoker, known hypertensive, was on oral anticoagulation (apixaban) for paroxysmal atrial fibrillation. He was diagnosed with chronic kidney disease in 2019 and was on conservative treatment until March 2020 when he was instituted on hemodialysis via an uncuffed right internal jugular venous catheter. He opted for peritoneal dialysis and chronic ambulatory peritoneal dialysis (CAPD) was initiated after 2 weeks of peritoneal catheter insertion. Eight months later, he had COVID-19-related pneumonia but recovered with supportive care. In March 2021, he was referred to the emergency room (ER) for intractable chest pain radiating to the right side of the chest. On physical examination, he had pallor, minimal pedal edema, and a group of matted jugular lymph nodes with rubbery consistency and a stony hard right supraclavicular lymph node. High-resolution computed tomography (CT) chest was performed that suggested a mass in the right lower lobe that was locally invading the mediastinum and large filling defects (2.3 cm*3 cm) were observed in the left atrium suspicious of tumor thrombi extending into the right pulmonary vein (Fig. 1a, b). Magnetic resonance imaging (MRI) of the lumbosacral spine showed the tumor mass invading the seventh and the eighth vertebral foramina causing nerve compression. He underwent a true cut biopsy of the right supraclavicular lymph node and simultaneous CT-guided biopsy of the lung mass. Histopathological examination of the jugular node showed epitheloid cell granuloma, along with rare giant cells with focal necrotic debris with an overall picture suggestive of tuberculosis. His biopsy of the lung mass was suggestive of a non-small cell lung cancer. Transesophageal echocardiography (TEE) was performed which showed a large oscillatory mass (2.5*3.0 cm) attached to the upper right pulmonary vein and extending into the left ventricle through the mitral leaflet. The patient was started on anti-tuberculosis treatment and planned for radiotherapy followed by chemotherapy as the tumor deemed surgically inoperable due to stage IV disease (T4) and active tuberculosis. The patient developed sudden onset confusion and dysarthria; MRIhead showed an acute infarct in the left frontal area and the anti-platelets and statins were added to the ongoing anticoagulation. Palliative radiation with Volumetric Modulated Arc Therapy (VMAT) technique was planned for 40 Gy in 15 fractions. The patient could complete 8 out of the 15 planned sessions as after the eighth session he became comatosed and the repeat diffusion-weighted MRIhead showed multiple acute infarcts bilaterally present in the fronto-parietal and temporo-occipital region, basalganliothalamic regions, cerebellar hemispheres, and cerebral vermis (Fig. 2a-c). Patient in view of poor sensorium got intubated the same day and later suffered a cardiac arrest and could not be revived.