Accidental intraventricular vincristine administration: an avoidable iatrogenic death.
A patient with acute lymphoblastic leukaemia was mistakenly given vincristine intraventricularly, as part of an intensified course of chemotherapy. Despite a CNS washout and supportive treatment, the patient developed progressive ascending paralysis, gradually lapsed into coma and died some 10 days later. Autopsy and post-mortem histological examination showed evidence of brain death caused by florid encephalomyelitis, apparently induced by the intraventricular administration of vincristine.
Lau
G
G
Department of Forensic Medicine, Institute of Science and Forensic Medicine, Singapore, Republic of Singapore.
D000328:Adult; D000972:Antineoplastic Agents, Phytogenic / Q000008:administration & dosage / Q000506:poisoning*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007276:Injections, Intraventricular / Q000009:adverse effects; D007945:Leukemia, Lymphoid / Q000188:drug therapy*; D008508:Medication Errors; D014750:Vincristine / Q000008:administration & dosage / Q000506:poisoning*
D000972:Antineoplastic Agents, Phytogenic; D014750:Vincristine