Diagnosing an atypical case of tuberculosis presenting as dacryocystitis: Sac biopsy and GeneXpert

Objective: To present an atypical case of tuberculous dacryocystitis. Method: An adult female presented with long standing epiphora with gradual swelling over lacrimal sac region. On syringing, water was felt in throat with no regurgitation. CT-DCG and CECT orbit were done subsequently and simultaneously. Ill-defined, enhancing soft tissue surrounding and involving the lacrimal sac wall was identified. The sac wall outline was seen distorted with contrast in NLD. The histopathology was suggestive of non-specific chronic inflammation. GeneXpert analysis was shown to be very low positive for M. tuberculosis. Montoux test was strongly positive (40 x 40 mm). ATT was started. Results: The swelling and watering subsided over the next few months. Conclusion: Tuberculosis should be considered in cases of chronic granulomatous dacryocystitis. CECT with CT-DCG is essential imaging. GeneXpert is a new and sensitive tool with considerable specificity in cases in which histopathology is not conclusive. ATT is curative and DCR is reserved for only unresolved NLDO with persistent epiphora.