Effects of an inadvertent dose of cytarabine in a child with Fanconi's anemia: reducing medication errors.
We report the case of a 7-year-old boy with Fanconi's anemia, who underwent a bone marrow transplant using an unrelated donor, and who received an inadvertent dose of cytarabine (cytosine arabinoside). The cytarabine was given by mistake 6 months following transplant. This caused excessive toxicity to many systems, including the pulmonary and renal systems. The patient recovered from the episode, but this article further highlights the acute adverse effects of cytarabine. Furthermore, it is the first report of excessive toxicity to cytarabine in a child with Fanconi's anemia. The article also highlights the problems of medication administration errors, particularly in those exquisitely sensitive to the effects of toxic drugs.
Trigg
Michael E
ME
Division of Blood & Bone Marrow Transplantation, Department of Pediatrics, A.I. duPont Hospital for Children, Wilmington, Delaware 19803, USA. mtrigg@nemours.org
Nadkarni
Vinay
V
Chidekel
Aaron
A
McKay
Charles
C
Meek
Rita
R
Griffin
Gregory
G
Edelson
Maureen
M
Reilly
Anne
A
Peoples
Joseph
J
Levine
Stuart
S
Meier
Frederick
F
D016026:Bone Marrow Transplantation / Q000009:adverse effects; D002648:Child; D000075202:Contraindications; D003561:Cytarabine / Q000009:adverse effects*; D005199:Fanconi Anemia / Q000188:drug therapy* / Q000276:immunology / Q000601:surgery; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D008297:Male; D008508:Medication Errors / Q000009:adverse effects* / Q000379:methods / Q000517:prevention & control
D007166:Immunosuppressive Agents; D003561:Cytarabine