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Mollaret's meningitis and pituitary failure associated with a Rathke’s cleft cyst

A 58-year-old female horse trainer with a prior history of migraines was referred for assessment of recurrent meningitis. She initially presented with a 3-week history of headaches with photophobia, vomiting, fevers and night sweats. Her symptoms improved within 72 h and she was discharged. However, she deteriorated while receiving outpatient parenteral antimicrobial therapy and required readmission 3 days later. Despite a further 14 days of therapy with broad-spectrum antibiotics her symptoms only partially resolved. Onarrival shewas complainingofnausea andheadache. She had anorexia, but had not lost weight and denied any unwell human or animal contacts. Temperature was 39.2 C and she was noted to have neck stiffness. She had no rash or lymphadenopathy. Neurological examination and visual fields were normal. Cardiovascular, respiratory, breast and abdominal examinations were normal. She had no genital lesions. Her therapy was continued with ceftriaxone and then trimethoprim–sulfamethoxazole for presumptive treatment of nocardia meningitis. Her symptoms resolved over 5 days, but recurred twice in the following 6 weeks without relation to antibiotic therapy. Each recurrence was of approximately 3 days duration. Cerebrospinal fluid (CSF) examination while she was symptomatic showed Mollaret’s cells (Fig. 1), a neutrophilic pleocytosis (white cell count 3350 10/L, 70% polymorphs), low glucose 1.5 mmol/L and markedly increased protein 4000 mg/L. These changes largely resolved, but recurred with further episodes. CSF