Intrathecal vincristine: fatal myeloencephalopathy despite cerebrospinal fluid perfusion.
BACKGROUND
Vincristine, an antineoplastic agent, must never be injected intrathecally because of its devastating neurotoxic effects, which are usually fatal. We report a case of fatal myeloencephalopathy secondary to inadvertent intrathecal administration of vincristine.


METHODS
Intrathecal vincristine was inadvertently injected into a twelve-year-old girl with acute lymphocytic leukemia. The error was immediately recognized and treated with cerebrospinalfluid drainage and cerebrospinal fluid exchange. Clinical evolution during the 83 days until death is described Multiple samples of cerebrospinal fluid were assayed for vincristine sulfate. Neuropathological post-mortem changes in the brain and spinal cord are reported


CONCLUSIONS
We compare our case with other previously reported cases in which patient survival was achieved with the same treatment. We summarize preventive measures to avoid such unfortunate occurrences.
Alcaraz
Andrés
A
Department of Pediatrics, Hospital Central de Asturias, Oviedo, Spain.
Rey
Corsino
C
Concha
Andrés
A
Medina
Alberto
A
D000972:Antineoplastic Agents, Phytogenic / Q000008:administration & dosage / Q000134:cerebrospinal fluid / Q000506:poisoning*; D002648:Child; D004679:Encephalomyelitis / Q000139:chemically induced* / Q000473:pathology; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007278:Injections, Spinal / Q000009:adverse effects*; D008508:Medication Errors; D014750:Vincristine / Q000008:administration & dosage / Q000134:cerebrospinal fluid / Q000506:poisoning*
D000972:Antineoplastic Agents, Phytogenic; D014750:Vincristine