BackgroundGranulomatosis with polyangiitis (GPA, formerly Wegener’s granulomatosis) is a multisystem vasculitis of small- to medium-sized blood vessels. Cranial involvement can result in cranial nerve palsies and, rarely, pituitary infiltration.Case presentationWe describe the case of a 32 year-old woman with limited but severe GPA manifesting as progressive cranial nerve palsies and pituitary dysfunction. Our patient initially presented with localised ENT involvement, but despite treatment with methotrexate, she deteriorated. Granulomatous inflammatory tissue around the skull base resulted in cavernous sinus syndrome, facial nerve palsy, palsies of cranial nerves IX-XII (Collet-Sicard syndrome), and the rare complication of cranial diabetes insipidus due to pituitary infiltration. The glossopharyngeal, vagus and accessory nerve palsies resulted in severe dysphagia and she required nasogastric tube feeding. Her neurological deficits substantially improved with treatment including high dose corticosteroid, cyclophosphamide and rituximab.ConclusionsThis case emphasises that serious morbidity can arise from localised cranial Wegener’s granulomatosis in the absence of systemic disease. In such cases intensive induction immunosuppression is required. Analysis of previously reported cases of pituitary involvement in GPA reveals that this rare complication predominantly affects female patients.

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While secondary solid cancer into the eye orbit is rare, it is the most common site for primary metastasis in female breast cancer. We report a case of a sixty-six years old woman presenting to her optician with complaints of double vision. Magnetic resonance imaging revealed an invasive lesion in the superior and medial rectus muscles of the right orbit, biopsy of which confirmed this as an infiltrating breast carcinoma. Investigation of the primary lesion showed an advanced invasive ductal carcinoma of the right breast. She was then treated with radiotherapy to the orbit and a non steroidal aromatase inhibitor Anastrozol (Arimidex®). We herein review and discuss the literature, epidemiology, mechanism of tumor spread, the "seed and soil" theory, clinical presentation, pathology, and management of this uncommon presentation.

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