Background Choosing a safe disease modifying therapy during the COVID-19 pandemic is challenging. This case series study was conducted to determine the incidence rate and the course of Covid-19 infection in MS/NMOSD patients treated with Rituximab. Methods In this study, we designed a web-based questionnaire. Baseline information such as patient- reported walking disability, total number of Rituximab infusions received, delayed injections, occurrence of any relapse, and the use of corticosteroids during the pandemic were collected. Also, information regarding the Covid-19 pandemic such as adherence to self-isolation, any recent exposure to an infected individual and the presence of suggestive symptoms were collected. In case of positive test results, patients were grouped into 2 categories; mild to moderate and seriously ill and outcomes were evaluated as favorable (improved/ discharged) and unfavorable (expired). Results Two hundred fifty-eight patients with Multiple Sclerosis were enrolled in this study, 9 of the subjects (3.4%) were confirmed positive for Covid-19, five of which required hospitalizations (55.5%), two patients required ICU admission (22.2%) and 2 two patients died (22.2%). None of these patients ever mentioned using corticosteroids during the pandemic. In comparison to MS patients who were not receiving disease modifying therapy (DMT), our study indicated a higher incidence of Covid-19 infection, higher ratio of serious illness and a higher fatality ratio. Conclusions Rituximab seems not to be safe enough during the pandemic.

Since March 2020, the pandemic of Coronavirus Disease 2019 (COVID-19) has become a threat for global health. Thereafter, several kinds of Coronavirus-associated disorders, including vascular involvements with neurologic symptoms, have been reported worldwide. Here, we describe two cases of COVID-19 with no history of traumatic brain injury nor vascular injuries who developed spontaneous subdural hematoma (SDH) in a subacute process. Both cases became lethargic and unresponsive during admission in intensive care unit. Both cases have undergone emergent craniotomy with acceptable outcome. The first patient improved significantly and was discharged a week after surgery. However, the second case had no improvement on her consciousness and died three days after surgery. Hemorrhagic events, including SDH, can happen during COVID-19 infection with several possible mechanisms. Brain imaging and further neurologic evaluation must be performed in any COVID-19 patients with signs of alteration in the state of consciousness.

A 38-year-old female, born to a consanguineous marriage, with a 2-year history of neuropsychiatric symptoms and mental decline, referred to our center for further assessments. On admission, she was bedridden and unable to talk and obey orders. She had severe rigidity and spasticity of extremities with brisk muscle stretch reflexes and bilateral Babinskie sign. She also had jerky movements of the limbs, consistent with myoclonus. Ophthalmological examination revealed neither optic atrophy nor retinopathy. MRI of the brain showed symmetric and extensive iron deposition in bilateral caudates, putamens, globus pallidi (GP), and SN (Fig. 1). Whole-exome sequencing revealed a homozygous mutation in the C19orf12 gene (NM_001031726.3: c.32C>T (p.Thr11Met), indicative of a diagnosis of mitochondrial membrane proteinassociated neurodegeneration (MPAN). MPAN is a subtype of neurodegeneration with brain iron accumulation syndromes caused by mutation in the C19orf12 gene. Clinically, MPAN presents with progressive spasticity, dystonia-parkinsonism, optic atrophy, motor neuronopathy, and neuropsychiatric and cognitive symptoms. 1 Although iron deposition in the SN and GP are typical of MPAN, there is one other case report of MPAN with iron deposition in the putamen and caudate nuclei. 2 This case is 1 of 2 cases with the oldest onset age reported so far in MPAN and suggests that p.Thr11Met mutation in the C19orf12 gene may cause a late-onset form of the disease with a rapidly progressive course and extensive iron deposition in the brain.

Background: Rituximab is a monoclonal antibody widely used in the treatment of inflammatory and autoimmune disorders. Despite reports of its effectiveness in the treatment of demyelinating diseases of central nervous system (DDCNS), it is not yet approved for use in these disorders. The aim of this study was to investigate the effectiveness and safety of low dose rituximab in three different subgroups of DDCNS including relapsing-remitting multiple sclerosis (RRMS), secondary-progressive multiple sclerosis (SPMS) and neuromyelitis-optica-spectrum disorders (NMOSD).Methods: In a prospective cohort study, we monitored expanded-disability-status-scale (EDSS), relapses (new attacks) and serum-IgG levels to assess effectiveness and drug-adverse-events for safety in patients with RRMS, SPMS and NMOSD. These patients were candidates to receive rituximab according to our common practice protocol. We switched patients to rituximab if there was poor response to first line therapies. We follow a low dose protocol in our center (500 mg twice, two weeks apart, repeating every six months) and these patients treated in a 4-year period were assessed retrospectively for evaluation of our protocol’s safety and effectiveness. Results: 99 patients (42 RRMS, 43 SPMS and 14 NMOSD) received rituximab for a range of 12 to 40 months period. New attacks occurred in 8 RRMS (19%), 10 SPMS (23%) and 1 NMOSD (7%) patients. EDSS decreased in RRMS and NMOSD cases. Serum-IgG levels decremented in SPMS and NMOSD patients. Drug-adverse-events happened in two cases.Conclusion: In this study, low dose rituximab showed substantial effectiveness in preventing disease progression with a considerably good safety profile.