Objective To describe presenting symptoms, clinical outcomes, and therapeutic management of concurrent Coronavirus disease 2019 (COVID‐19) infections in patients with a pre‐existing myasthenia gravis (MG). Methods We conducted a retrospective study in patients with preexisting MG presenting with concurrent COVID‐19 between September 21st and November 4th, 2020 when attending the emergency department or routine neurology consultation at the National Institute Mongi Ben Hamida of Neurology of Tunis, Tunisia. Results Five patients were identified. The Myasthenia Gravis Foundation of America scores (MGFA) prior to COVID‐19 infection were class I in one patient, class II (IIa, IIb) in two patients, and class IIIb in one patient. Four patients had mild to moderate courses of COVID‐19 infection. One patient presented a critical infection with acute respiratory disease syndrome (ARDS) requiring mechanical ventilation. Two of them also demonstrated signs of MG exacerbation requiring the use of intravenous immunoglobulin in one case. We maintained immunosuppressant therapy to MG in all our patients. All our patients received Azithromycin (AZM) as a part of specific drug treatment of COVID‐19 infection. Outcome was favorable in 4 patients and rapidly fatal evolution was observed in the patient with ADRS. Discussions and conclusion The results from our study suggest that prior MG activity could partially influence the subsequent clinical outcomes. It emerged also that ongoing long‐term immunosuppressive immunotherapy to MG should be maintained during the COVID‐19 pandemic and that AZM can be used safely in MG patients and concurrent COVID‐19 infection.

Gadolinium diethylenetriamine penta-acetic acid (Gd-DTPA) is the main contrast agent used in MRI, known for its good tolerance and rare toxicity. Even intrathecal injection of limited doses of Gadolinium can be performed in some indications. To our knowledge, only 3cases of accidental intraventricular injection of Gadolinium have been yet reported in the literature. We report the case of a 40-year-old male patient, who presented with headaches and vomiting. Brain MRI showed a right parietal abscess. The patient underwent emergent surgery for drainage of the septic collection. Postoperative MRI showed the development of a hydrocephalus related to a ventriculitis. Another surgery was performed to set up an external ventricular shunt, which lead to an improvement of the neurological status. A control brain MRI was scheduled for the patient, which revealed extensive abnormal enhancement inside the right lateral ventricle, on the basal cisterns as well as a leptomeningeal enhancement. Shortly after Gadolinium injection, the patient presented a tonic-clonic seizure. This clinico-radiological context leads to discover of the inadvertent intraventricular administration. Afterward, the patient's condition quickly deteriorated. Two days after the MRI he presented a cardiorespiratory arrest followed by death. Direct administration of Gadolinium into a ventriculostomy mistaken for intravenous catheter is a rare but harmful situation. Despite their rarity, such cases prove the importance of tracing all lines to their insertion sites to be confident of their appropriateness for injection.