Case Report

Tubercular Osteomyelitis of the Orbit Presenting as
Periorbital Cellulitis

Shruti Bhattacharya, MBBS; Usha K Raina, MD; Shantanu K Gupta, MS; Manisha Mishra, MS; Varun Saini, MS
Brajesh Kumar, MBBS

Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India

Abstract

Purpose: Osteomyelitis of the orbital bones presenting as an orbital cellulitis is a
rare form of extrapulmonary tuberculosis (TB). We report a rare case of tubercular
osteomyelitis of the orbital bones presenting as a periorbital cellulitis.
Case Report: A seven-year-old female child presented to our tertiary eye care center
with swelling involving the right eyelids and the right cheek for two months. She had
been provisionally diagnosed elsewhere as pre-septal cellulitis and had been given oral
antibiotics. We clinically diagnosed her as orbital cellulitis, but her non-responsiveness to
intravenous antibiotics prompted us to get a contrast enhanced computed tomography
(CECT) of the orbit and paranasal sinuses, which was suggestive of tubercular etiology.
However, the patient had no foci for TB elsewhere. We used a relatively new, but
rapid test, called Cartridge-based Nucleic Acid Amplification Test (CBNAAT) on the pus
aspirate which was positive for TB. Thereafter, the patient was started on anti-tubercular
treatment to which she responded wonderfully.
Conclusion: A high index of suspicion should be kept for TB infection in cases of orbital
cellulitis with unusual clinical behavior in an endemic region such as India.

Keywords: Orbital Tuberculosis; Periorbital Cellulitis; Tubercular Osteomyelitis

J Ophthalmic Vis Res 2022; 17 (1): 146–149

INTRODUCTION

Tuberculosis (TB) is a major cause of morbidity and
mortality in developing nations. It is a multisystem
infectious disease caused by Mycobacterium
TB. TB may be pulmonary or extrapulmonary

Correspondence to:

Manisha Mishra, MS. Guru Nanak Eye Centre, Maulana
Azad Medical College Campus, Bahadur Shah Zafar
Marg, New Delhi 110002, India.
E-mail: manisha.mishra4266@gmail.com
Received 28-08-2019; Accepted 22-05-2020

Access this article online

Website: https://knepublishing.com/index.php/JOVR

DOI: 10.18502/jovr.v17i1.10181

depending on whether lungs are the primary site of
infection or not.

Ocular tuberculosis (OTB) is a manifestation of
extrapulmonary TB. It is considered rare even in
endemic areas. OTB may be primary or secondary.
When the eye is the initial portal of entry of the
bacteria, it is considered a primary ocular TB.
In secondary ocular TB, the involvement of the
eye is due to spread from hematogenous route or

This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work non-commercially, as
long as appropriate credit is given and the new creations are licensed under the
identical terms.

How to cite this article: Bhattacharya S, Raina UK, Gupta SK, Mishra M, Saini
V, Kumar B. Tubercular Osteomyelitis of the Orbit Presenting as Periorbital
Cellulitis . J Ophthalmic Vis Res 2022;17:146–149.

146 © 2022 Bhattacharya et al. THIS IS AN OPEN ACCESS ARTICLE DISTRIBUTED UNDER THE CREATIVE COMMONS ATTRIBUTION LICENSE | PUBLISHED BY KNOWLEDGE E

http://crossmark.crossref.org/dialog/?doi=10.18502/jovr.v17i1.10181&domain=pdf&date_stamp=2019-07-17
https://knepublishing.com/index.php/JOVR


Tubercular Orbital Osteomyelitis ; Bhattacharya et al

from adjacent structures.[1] Ocular TB may have
myriad presentations depending upon the site of
infection as well as the severity. However, uveal
involvement is more common because of its high
blood supply.[2, 3]

Orbital TB is more commonly seen in children
with a female predisposition. It is insidious in
onset and is usually unilateral.[4] It may present
as unilateral proptosis/draining sinus tract/orbital
swelling/lid swelling/radiographic features of bony
destruction.

We present a rare case of tubercular
osteomyelitis of the orbital bones masquerading
as periorbital cellulitis.

CASE REPORT

A seven-year-old female child presented to our
tertiary eye care center with tender swelling
involving the right eye and the right cheek for two
months. This was not associated with decrease in
vision, discharge, photophobia, or fever.

On examination, the swelling involved the right
upper and lower eyelid along with the right
upper cheek; it was firm in consistency, tender
and warm to touch, erythematous, with negative
fluctuation tests, and no pus points or discharging
sinuses (as shown in Figures 1A & 1B). Visual
acuity was 6/6 in both eyes. Anterior as well
as posterior segment examination of the eye
were unremarkable. Despite the extensive edema,
extraocular movements were full and free. Direct
and consensual light reflexes were normal. A note
was made of the enlarged submandibular lymph
nodes. These were 2 × 2 cm, non-tender, non-
conglomerated, firm in consistency, not fixed to the
overlying skin. The overlying skin was not red and
non-tender. The child was otherwise afebrile and
had no other systemic complaints.

Furthermore, the patient was being treated with
oral antibiotics (no records brought) at a peripheral
center for the past one month before presentation
to our center, with a steady increase in the size of
the swelling. History elicited from the attendants
showed their noncompliance with the prescribed
treatment. Thereafter, the child was admitted
for a course of intravenous antibiotics, with the
provisional diagnosis being orbital cellulitis.
However, poor response to intravenous antibiotics
even after one week prompted us to investigate
further. A contrast enhanced computerized

tomography of the orbit and the paranasal sinuses
(PNS) was ordered which showed a peripherally
enhancing collection in the anterolateral aspect
of the right maxillary sinus and zygomatic arch,
extending superiorly along the lateral aspect of
right orbit, showing lytic erosive changes, along
with periosteal thickening and bony sequestration
in the zygoma (axial scan shown in Figure 3A &
3B). These radiographic features were suggestive
of TB.

The child had no history of fever, night sweats,
no previous history of TB, and no history of contact
with TB. In addition, the swelling was not like
a typical tubercular cold abscess and the lymph
nodes were not matted nor fixed to the skin. But
in view of high endemicity of TB in our country, it
was still kept on top of our differentials.

Except for a raised erythrocyte sedimentation
rate (ESR), the complete blood count and liver
function tests were unremarkable. The tuberculin
sensitivity test (TST) showed 20 mm after 48
hr - however this is nonspecific. Fine needle
aspiration cytology (FNAC) was done from the
swollen submandibular lymph nodes – it showed
necrotic changes but no granuloma or acid fast
bacilli (AFB). Sputum as well as gastric aspirate
microscopy for AFB showed no evidence of AFB.

Antigravity aspirate of the swelling was done
with a 26-gauge needle, under local anesthesia.
Around 1 ml of the watery yellowish aspirate was
then sent for gram stain, bacterial and fungal
cultures, and a relatively new test – the Cartridge-
based Nucleic Acid Amplification Test (CBNAAT),
also known as the Genexpert test. CBNAAT
turned out to be positive, thus confirming the
diagnosis of primary tubercular osteomyelitis of
the right maxilla; the bacterial and gram stain
reports were negative, thus ruling out secondary
superinfection. The child was put on a four-
drug anti-tubercular treatment (isoniazid [10 mg/kg]
rifampicin [15 mg/kg], ethambutol [20 mg/kg], and
pyrazinamide [35 mg/kg]) and responded well
to the treatment, by complete shrinkage of the
swelling within six weeks [Figures 2A & 2B].

DISCUSSION

Tuberculosis (TB) is a major health problem in
developing countries. However, even in endemic
areas, orbital TB is a rare entity. Orbital TB
can be diagnosed using the following criteria: (1)

JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2021 147



Tubercular Orbital Osteomyelitis ; Bhattacharya et al

clinical/radiological or histological evidence of TB
from the orbital lesion associated with evidence
of TB elsewhere, (2) demonstration of AFB in
the orbital lesion, (3) isolation of mycobacteria in
culture from biopsied tissue, and (4) demonstration
of mycobacterial infection by doing a PCR on the
biopsied tissue.[5]

Orbital TB has been clinically classified into
five categories: classical periostitis, orbital
tuberculoma with no bony destruction, orbital
TB with evidence of bony destruction (not
classified as classical periostitis), orbital TB as
a result of spread from paranasal sinuses and
dacryoadenitis. Patients with classical periostitis
present with chronic ulceration or discharging
sinus in the periorbital region. There may or may
not be evidence of bony erosion or sclerosis
radiographically. Orbital tuberculoma presents
with palpable mass, proptosis, or diplopia. When
radiologic evidence of bony destruction, osteolytic
changes, or erosion is seen, it is classified as
orbital TB with bony destruction. Maxillary sinus
is the most commonly involved sinus from which
TB can spread to orbit. Such patients usually
present with proptosis and dystopia of the globe.
Patients with tubercular dacryoadenitis present
with a mass in the lacrimal region and regional
lymphadenopathy.[5, 6] Osteomyelitis of tubercular
origin involving the orbital bones is rare. Mandible
is the most common craniofacial bone affected
by TB.[7] This condition is usually secondary to
a primary tubercular lesion elsewhere, such as
the lungs and the abdomen. However, primary
involvement of these bones have also been
reported.

Our patient presented with swelling involving
the right periorbital region extending up to the
right cheek. She was given a course of antibiotics
to which no response was seen and the patient
was investigated for other etiologies including TB.
Our differentials at this time were local cellulitis,
neoplasia, pseudotumor, easophillic granuloma,
and TB, and she was investigated for all of these
diagnoses.

Incision and drainage of the swelling was not
done because an incision and drainage (I&D) would
lead to a persistently discharging sinus in case it
was tubercular in etiology.

There was no histopathology evidence of TB
but radiologically the lesion was suggestive of TB
which was done a week later after no response

to intravenous antibiotics. We waited for a week
before imaging was done because the history of
treatment given to her was very uncompliant and
no intravenous antibiotics were given before the
patient presented to us.

We did keep in mind other conditions causing
lytic changes in the orbit such as neoplastic,
inflammatory, and rare causes like eosinophilic
granulomas. Our diagnosis of TB was confirmed by
CBNAAT test done on the sample from the orbital
lesion. Thereafter, the patient was started on anti-
tubercular drugs.

We should keep a high index of suspicion
for orbital TB in cases like ours especially in
endemic areas such as India. The patient should be
investigated for the same. However, the diagnosis
is often challenging in cases of extrapulmonary
TB as the number of TB bacilli is often low in
these sites.[8] Although the demonstration of AFB
in culture is considered the gold standard for
diagnosis, it may take up to six to eight weeks, thus
delaying the treatment.[9]

Molecular diagnostics such as nucleic acid
amplification test play an important role in cases of
extrapulmonary TB. A new breakthrough has been
the CBNAAT, also known as the Genexpert test.
This test not only detects Mycobacterium DNA but
also reveals whether it is sensitive to rifampicin
or not, thereby identifying multidrug-resistant TB
cases. The main advantage of CBNAAT is the
speed and accuracy with which it works. It has been
shown to have comparable results with culture
(which may take up to six to eight weeks). However,
it has its own set of flaws such as high cost,
need for a stable electricity supply, replenishment
of the cartridges every 18 months, and a stable
temperature ceiling.[10]

Interferon gamma release assays can also be
used as an aid to diagnosis. These tests are based
on the production of interferon gamma by T cells
specific to antigens of tubercular bacilli. However,
they are less sensitive for detection of latent TB
infection.[1]

Radiological features of orbital TB include
destruction of bone, most commonly the frontal
and sphenoidal bones. There may or may not be
associated bony sclerosis, inflammation, abscess
formation which may extend to infratemporal fossa.
Lacrimal gland involvement may also be seen.
Involvement of lateral wall is usually suggestive of
hematogenous route of infection while involvement

148 JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2021



Tubercular Orbital Osteomyelitis ; Bhattacharya et al

of medial wall is indicative of spread from adjoining
paranasal sinuses. There may be associated pre-
septal thickening.[11]

Treatment of tubercular osteomyelitis is mainly
done using anti-tubercular drugs. Surgery is
indicated in cases with extensive destruction,
presence of secondary infection, and intracranial
involvement. Our patient was managed medically
by anti-tubercular treatment.

To conclude, although orbital TB is rare, it should
still be kept in mind while seeing patients with
orbital lesions in an endemic country, and new
tests such as CBNAAT should be used more
frequently because of increased sensitivity and
rapid diagnosis.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

REFERENCES

1. Shakrachi FI. Ocular tuberculosis: current perspective. Clin
Ophthalmol 2015;9:2223–2227.

2. Helm CJ, Holland GN. Ocular tuberculosis. Surv
Ophthalmol 1993;38:229–256.

3. Varma D, Anand S, Reddy AR, Das A, Watson JP, Currie DC,
et al. Tuberculosis: an under-diagnosed aetiological agent
in uveitis with an effective treatment. Eye 2006;20:1068–
1073.

4. Sen DK. Tuberculosis of the orbit and lacrimal gland: a
clinical study of 14 cases. J Pediatr Ophthalmol Strabismus
1980;17:232–238.

5. Mittala R, Sharma S, Rath S, Barik MR, Tripathy D. Orbital
tuberculosis: clinicopathological correlation and diagnosis
using PCR in formalin-fixed tissues. Orbit 2017;36:264–
272.

6. Madge SN, Prabhakaran VC, Shome D, Kim U, Honavar
S, Selva D. Orbital tuberculosis: a review of the literature.
Orbit 2008;27:267–277.

7. Sethi A, Sethi D, Agarwal AK, Nigam S, Gupta A. Tubercular
and chronic pyogenic osteomyelitis of cranio-facial bones:
a retrospective analysis. J Laryngol Otol 2008;122:799–
804.

8. Lee JY. Diagnosis and treatment of extra pulmonary
tuberculosis. Tuberc Respir Dis 2015;78:47–55.

9. Singh KG, Tandon S, Nagdeote ST, Sharma K, Kumar A.
Role of CB-NAAT in diagnosing mycobacterial tuberculosis
and rifampicin resistance in tubercular peripheral
lymphadenopathy. Int J Med Res Rev 2017;5:242–246.

10. Sahana KS, Prabhu AS, Saldanha PRM. Usage of
Cartridge Based Nucleic Acid Amplification Test
(CBNAAT/GeneXpert) test as diagnostic modality for
pediatric tuberculosis; case series from Mangalore, South
India. J Clin Tuberc Other Mycobact Dis 2017;11:7–9.

11. Khalil M, Lindley S, Matouk E. Tuberculosis of the orbit.
Ophthalmology 1985;92:1624–1627.

JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2021 149