Tubercular osteomyelitis masquerading as acute dacryoadenitis

A girl in her second decade of life presented with a painful, progressively increasing S-shaped swelling of the right upper lid, suggestive of acute dacryoadenitis. She had a history of close contact with a tuberculosis (TB) patient. Despite improvement in preseptal cellulitis with broad-spectrum (non-tubercular) systemic antibiotics, a fluctuant swelling persisted. After resolution of preseptal cellulitis, a CT scan revealed possible tubercular osteomyelitis of the lateral orbital wall and a cold abscess in the right orbit. Ultrasonography-guided drainage of the abscess was performed, and the sample tested positive for Cartridge-based Nucleic Acid Amplification Test, confirming TB. The patient was started on antituberculosis treatment, leading to complete resolution of the swelling with no recurrence during a 2-year follow-up. This case emphasises the importance of maintaining a high index of suspicion for TB in cases of dacryoadenitis unresponsive to antibiotics, especially in endemic regions like India.