Hypertrophic cranial pachymeningitis and granulomatosis with polyangiitis.
Learning point for clinicians

This case highlights hypertrophic cranial pachymeningitis as an important cause of multiple cranial neuropathies. Investigation should focus on infection, neoplasia and vasculitis.

Consider urgent contrast magnetic resonance imaging brain for patients with granulomatosis with polyangiitis complaining of headache, particularly if cranial neuropathies are present. Early initiation of immunosuppression is important in preventing long-term disability.

A 55-year-old gentleman presented to the emergency department with an acute onset right facial droop. Bell’s palsy was diagnosed, and he was discharged home with a course of Prednisolone. However, within 2 weeks, the patient was unable to swallow and he was readmitted with an aspiration pneumonia necessitating intubation and ventilation.

One year previously, he had presented as an outpatient with small joint pain, elbow synovitis, significant …