A Rare Case of Cryptogenic Orbital Basal Cell Carcinoma with Perineural Spread

A 74-year-old man presented in July 2017 with acute right eye ptosis, diplopia, and right facial pain. He was a vasculopath with a history of prostate cancer, previously resected facial SCC, and MGUS. Two months prior, he had a diagnosis of right trigeminal neuralgia treated with microvascular decompression without symptomatic improvement. On present examination he had complete right CN3 palsy with pupillary involvement and right CN 4 and 6 palsies. He had normal afferent visual function. On MRI brain/orbits he had enhancement of right superior oblique, V1, V2, CN3, and right cavernous sinus without meningeal thickening. LP demonstrated a small, monoclonal B-cell population. Right supraorbital nerve biopsy was normal. He was tentatively diagnosed and treated for leptomeningeal lymphomatosis secondary to B cell lymphoma.