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Could a Texas mayor really derail the treason trial of Pakistan’s former military strongman? That’s a possibility, after a dramatic twist Thursday in the ongoing court case against General Pervez Musharraf.

A court in Islamabad was shown a letter from the ex-ruler’s longtime heart doctor, Arjumand Hashmi, who said Musharraf, 70, should be transferred to the United States for urgent treatment following an “alarming” deterioration in his condition.

Pakistan-born Hashmi, who has been treating Musharraf since 2006, is the Director of Interventional Cardiology at the Paris Regional Medical Center in Paris, Texas. He is also mayor of the city, which has a population of about 25,000.

The bombshell letter prompted the court to commission a fresh report into Musharraf’s health, after prosecutors complained that the ex-ruler’s lawyers were using the letter as an excuse for his repeated non-attendance at trial hearings.

It also prompted speculation in Pakistan that prosecutors could cut a deal with Musharraf – if his deteriorating health is verified - allowing the one-time ruler to choose between fleeing to permanent exile abroad or attend trial for treason, risking conviction and a possible death sentence.

Musharraf, who seized power in a military coup in 1999 and ruled until 2008, was once a staunch ally of then-U.S. president George W. Bush.

There has been abundant local commentary doubting the extent of Musharraf’s of ill-health. He gave back-to-back media interviews and showing off his luxury home in the days prior to his Jan. 2 admission to a military hospital, and an initial report last week by the Armed Forces Institute of Cardiology did not raise any red flags.

Akram Sheikh, the chief prosecutor in the case, told the court that Musharraf was “is hiding in a military hospital.”

However, Musharraf’s biographer and longtime friend, Humayun Gauhar, believes the former ruler’s problems are genuine.

“This is not a made up story,”Gauhar said from Islamabad Thursday. “I met him every night for dinner prior to his Jan. 2 medical incident and listened to him complain about the pain in the left side of his jaw and the problems he had chewing his food.”

Gauhar said it was Musharraf’s police detail - not Musharraf himself - who insisted on hospital treatment.

He also cast doubt on whether Musharraf would choose to live in exile – a move that would be interpreted in Pakistan as a flight from justice and a victory for his enemies in the civilian government. “He is determined to stay, to fight and to clear his name," Gauhar said.

An independent report on Musharraf’s health will be issued on Jan. 24.