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Rituximab is a human/murine chimeric immunoglobulin monoclonal antibody that binds to CD20, a B-cell lymphocyte transmembrane protein. Rituximab been used in the treatment of various hematologic malignancies.1 More recently, rituximab was found to have utility in treating pemphigus vulgaris (PV). The US Food and Drug Administration approved its use in 2018 for treatment of moderate-to-severe pemphigus vulgaris following a randomized trial that demonstrated superior efficacy and fewer adverse events when used in conjunction with prednisone compared with prednisone alone.2,3 As an immunomodulator, rituximab carries a black box warning for potentially fatal infusion reactions, severe mucocutaneous reactions, hepatitis B virus reactivation, and progressive multifocal leukoencephalopathy (PML).2 Rarely, rituximab has been associated with cerebral toxoplasmosis infection.4, 5, 6, 7 Here we present a case of cerebral toxoplasmosis infection in a patient treated with rituximab for pemphigus vulgaris, along with a brief review of central nervous system (CNS) toxoplasmosis in the setting of rituximab therapy.

The outbreak of coronavirus disease 2019 (COVID-19) has disproportionately affected patients with comorbidities, including recipients of solid organ and hematopoietic stem cell transplants (SCT). Upon recovery from COVID-19, the degree of the immunological protection from reinfection remains unclear. Here we describe a 33-year-old patient with erythropoietic protoporphyria (EPP) who had undergone liver transplantation with splenectomy followed by allogeneic SCT in 2013 after an initial failed liver and umbilical cord transplant. The patient developed mild upper respiratory symptoms in the spring of 2020 and was found to have anti-SARS-CoV2 antibodies suggesting past infection. A comprehensive analysis of T cell functionality in peripheral blood from this patient revealed robust in vitro responses against SARS CoV2 antigens Spike (S) 1 and 2, membrane (M) and nucleoprotein (NP), comparable to the reactivity against common antigens from CMV, EBV, Ad and BK viruses, while only low reactivity was seen in healthy donors without documented history of COVID-19. Moreover, the patient displayed a marked recognition of counterpart antigens from related human coronaviruses (hCoVs) 229E, OC43, NL63 and HKU1. Thus, despite lifelong immunosuppression, this survivor of COVID-19 retained a remarkable degree of immunocompetence and showed broad-spectrum T cell memory specific for SARS-CoV2 and related hCoVs including less studied hCoV M and NP antigens. The study highlights the role of cellular immunity after natural COVID-19 infection, suggesting broader use of T cell assays as a tool for risk stratification, measurement of immunocompetence and/or post-infection or post-vaccination protection, and possible T cell-based adoptive immunotherapy strategies in high-risk patients.

In this consensus statement, we provide updated recommendations on multiple sclerosis (MS) management during the COVID-19 crisis and the post-pandemic period applicable to neurology services around the world. Statements/recommendations were generated based on available literature and the experience of 13 MS expert panelists using a modified Delphi approach online. The statements/recommendations give advice regarding implementation of telemedicine; use of disease-modifying therapies and management of MS relapses during the pandemic; management of people with MS at highest risk from COVID-19; management of radiological monitoring; use of remote pharmacovigilance; impact on MS research; implications for lowest income settings, and other key issues.

Highlights • Recognition the etiologies of ATL is important due to its potentially reversible nature after treatment or removal of the toxin. • “CHOICES” is useful to memorize etiologies associated with PVWM injury in non-metabolic and non-infectious ATL patients. • Reduced diffusion is an early and important imaging finding to evaluate patients with non-metabolic and non-infectious ATL patients., Purpose To describe non-metabolic, non-infectious etiologies of acute toxic leukoencephalopathy (ATL) on DWI MRI, and provide a useful acronym to remember them. Material and Methods Our PACS archive was reviewed, yielding 185 patients with suspected ATL per MRI reports and clinical follow up; infectious or metabolic causes were excluded. Result/Discussion The 87 included non-infectious, non-metabolic ATL patients' etiologies are represented by the acronym 'CHOICES': chemotherapy ('C',n = 34); heroin-induced ('H',n = 6), opioid analogues ('O',n = 14); immunosuppressant ('I',n = 11) or imidazole (n = 2); cocaine ('C',n = 1); environmental or ethanol abuse ('E',n = 5), splenial lesions ('S',n = 9), and 'other' (n = 5). Conclusion The "CHOICES" acronym delineates various toxic etiologies of ATL.

Disease-modifying therapies (DMT) for relapsing-remitting MS (RRMS) act on the immune system, suggesting a need for caution during the SARS-CoV2/Covid-19 pandemic. A group of experts in MS care from Saudi Arabia convened to consider the impact of Covid-19 on MS care in that country, and to develop consensus recommendations on the current application of DMT therapy. Covid-19 has led to disruption to the care of MS in Saudi Arabia as elsewhere. The Expert Panel considered a DMT's overall tolerability/safety profile to be the most important consideration on whether or not to prescribe at this time. Treatment can be started or continued with interferon beta, teriflunomide, dimethyl fumarate, or natalizumab, as these DMTs are not associated with increased risk of infection (there was no consensus on the initiation of other DMTs). A consensus also supported continuing treatment regimens with fingolimod (or siponimod) and cladribine tablets for a patient without active Covid-19. No DMT should be imitated in a patient with active Covid-19, and (only) interferon beta could be continued in the case of Covid-19 infection. Vaccination against Covid-19 is a therapeutic priority for people with MS. New treatment should be delayed for 2-4 weeks for vaccination. Where treatment is already ongoing, vaccination against Covid-19 should be administered immediately without disruption of treatment (first-line DMTs, natalizumab, fingolimod), when lymphocytes have recovered sufficiently (cladribine tablets, alemtuzumab) or 4 months after the last dose (ocrelizumab). These recommendations will need to be refined and updated as new clinical evidence in this area emerges.