Orbital tuberculosis mimicking a vascular emergency: A case report of superior ophthalmic vein engorgement

We report a rare case of orbital tuberculosis (O-TB) in an elderly diabetic patient that mimicked a variety of vascular, infectious, and inflammatory orbital diseases. A 73-year-old woman with uncontrolled diabetes, unilateral swelling of the left eye, proptosis, and binocular diplopia, as well as left superior ophthalmic vein (SOV) engorgement on an orbital CT scan, was referred to our center to rule out a carotid-cavernous fistula (CCF) or a cavernous sinus thrombosis (CST). An MRI, MRV, and cerebral angiography ruled out both diagnoses. Nasal endoscopy revealed septal necrosis, and biopsy demonstrated infectious necrosis. Initial bacterial and fungal smear and cultures were negative. However, Ziehl–Neelsen staining and culture on Lowenstein–Jensen medium were positive for acid-fast bacilli, and PCR confirmed Mycobacterium tuberculosis. The patient was treated with anti-tuberculosis treatment and recovered two months after treatment. O-TB may rarely mimic a vascular emergency through isolated superior ophthalmic vein engorgement. Clinicians should specifically consider orbital tuberculosis in patients with orbital inflammation and vascular-mimicking imaging findings when routine vascular evaluations are inconclusive, particularly in tuberculosis-endemic regions, to avoid diagnostic delay and ensure timely and appropriate treatment.