A 27-year-old woman was diagnosed with ileocolonic nonstricturing, nonpenetrating Crohn's disease at the age of 17 years. Other comorbidities included osteopenia, previous erythema nodosum, sinusitis, and a positive lupus anticoagulant result. Her family history included autoimmune hemolytic anemia, GPA, and tuberculosis. In the 4 years following diagnosis, her Crohn's disease followed a steroid-refractory course complicated by stricturing of the large intestine, leading to a segmental transverse colon resection and right-sided double-barrelled colostomy. After 1 year, she underwent a loop ileostomy for a perforated internal hernia. In the subsequent 5 years, additional surgeries were also performed for reversal of the loop ileostomy and subsequent refashioning of the colostomy. Her treatments included several courses of corticosteroids, azathioprine (developed intolerance), infliximab (anaphylaxis), and later adalimumab with addition of methotrexate. While off adalimumab for 1 week (recurrent viral infections), she presented with a 2-day history of acute onset of bilateral painful S-shaped periorbital swelling, moderate erythema, and chemosis worse on the left with diplopia (Figure 2A). Ocular movements were restricted and episcleritis was evident. A CT scan of head, orbits, and sinuses revealed bilateral lacrimal gland enlargement. Lateral and superior recti were also enlarged (Figure 1E to F). Blood analysis showed raised inflammatory markers with a WCC of 21.6 x 109/L and a CRP of 166 mg/L, normal serum angiotensin-converting enzyme (ACE) levels, and thyroid function. Immunologic tests showed positive perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) and low proteinase 3 (PR3). Neither pulmonary nor renal involvement was present. Postoperative appearances are shown in Figure 2B. Histology showed a chronic dacryoadenitis, acute vasculitis of medium-sized vessels, and necrotizing histiocytic granulomas (Figure 3B). Stains for periodic acid-Schiff-diastase, Ziehl-Neelsen, and IgG4 were negative, and pus collected from the lacrimal gland during the biopsy did not reveal any microbial growth. The patient was started on a 2-day course of intravenous Co-amoxiclav (1.2 g 3 times daily) and an 8-week reducing course of high-dose oral prednisolone (commencing at 60 mg daily) for presumed OID complicating Crohn's disease. Following recommencement of weekly 25 mg subcutaneous methotrexate and biweekly adalimumab, her symptoms and signs had completely resolved at ophthalmological assessment 1 week later (Figure 2C).