Grand Rounds

A patient with a history of travel to Southeast Asia presented with a two-month history of left periorbital edema that was unresponsive to corticosteroid therapy and was found to have a palpable orbital lesion. He underwent orbitotomy and biopsy, which revealed a dense, sclerotic-appearing mass. Histopathologic evaluation demonstrated both necrotizing and non-necrotizing granulomatous inflammation with occasional acid-fast bacilli, findings concerning a mycobacterial infection. Concurrently, the patient developed progressive upper and lower extremity paresthesias and numbness. He was admitted for infectious disease and neurologic evaluation, and MRI demonstrated findings consistent with transverse myelitis. An extensive diagnostic workup, including lumbar puncture and serial sputum cultures, failed to isolate a causative organism. Nevertheless, given the overall clinical, histopathologic, and epidemiologic suspicion for mycobacterial infection, empiric antituberculous therapy was initiated. He was also treated with a course of intravenous methylprednisolone, resulting in gradual improvement of both his orbital and neurologic symptoms.

Presentation Date: 07/30/2026
Issue Date: 07/31/2026