title: Effects of an inadvertent dose of cytarabine in a child with Fanconi's anemia: reducing medication errors.
abstract: 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.
authors.affiliation: Division of Blood & Bone Marrow Transplantation, Department of Pediatrics, A.I. duPont Hospital for Children, Wilmington, Delaware 19803, USA. mtrigg@nemours.org
authors.forename: Michael E
authors.initials: ME
authors.lastname: Trigg
authors.forename: Vinay
authors.initials: V
authors.lastname: Nadkarni
authors.forename: Aaron
authors.initials: A
authors.lastname: Chidekel
authors.forename: Charles
authors.initials: C
authors.lastname: McKay
authors.forename: Rita
authors.initials: R
authors.lastname: Meek
authors.forename: Gregory
authors.initials: G
authors.lastname: Griffin
authors.forename: Maureen
authors.initials: M
authors.lastname: Edelson
authors.forename: Anne
authors.initials: A
authors.lastname: Reilly
authors.forename: Joseph
authors.initials: J
authors.lastname: Peoples
authors.forename: Stuart
authors.initials: S
authors.lastname: Levine
authors.forename: Frederick
authors.initials: F
authors.lastname: Meier
mesh_terms: 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
chemical_list: D007166:Immunosuppressive Agents; D003561:Cytarabine