title: Accidental overdose of intrathecal cytarabine in children.
abstract: OBJECTIVE
  To report 2 cases of intrathecal cytarabine overdose in children with cancer, neither of whom underwent cerebrospinal fluid (CSF) exchange per current recommendations or developed apparent toxicity related to the event.
  
  
  METHODS
  A 17-year-old female with newly diagnosed acute myeloid leukemia received 177 mg of intrathecal cytarabine rather than the appropriate dose of 70 mg. She was monitored closely with no apparent toxicity from the event. A 4-year-old boy with newly diagnosed precursor B-cell acute lymphoblastic leukemia received 175 mg of intrathecal cytarabine rather than the appropriate dose of 70 mg. CSF was immediately withdrawn and intrathecal hydrocortisone was instilled for possible antiinflammatory effect. He developed no apparent toxicity from the event.
  
  
  CONCLUSIONS
  Cytarabine is an important chemotherapeutic agent in the treatment of leukemia. One case report of intrathecal cytarabine overdose was identified in the literature, which recommended CSF exchange as management. Neither child in our report underwent CSF exchange or developed apparent toxicity related to the event. Institutional changes were made in both cases to prevent similar events.
  
  
  CONCLUSIONS
  These cases demonstrate that measures such as CSF exchange are not uniformly required for cytarabine overdose.
authors.affiliation: Division of Hematology-Oncology, Department of Pediatrics, University of Texas at Southwestern Medical Center, Dallas, TX, USA. rachel.thienprayoon@utsouthwestern.edu
authors.forename: Rachel
authors.initials: R
authors.lastname: Thienprayoon
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Heym
authors.forename: Lindsay
authors.initials: L
authors.lastname: Pelfrey
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Bowers
mesh_terms: D000293:Adolescent; D000964:Antimetabolites, Antineoplastic / Q000008:administration & dosage* / Q000134:cerebrospinal fluid; D002675:Child, Preschool; D003561:Cytarabine / Q000008:administration & dosage* / Q000134:cerebrospinal fluid; D062787:Drug Overdose; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage; D006801:Humans; D007278:Injections, Spinal; D015470:Leukemia, Myeloid, Acute / Q000188:drug therapy; D008297:Male; D008508:Medication Errors; D015452:Precursor B-Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy
chemical_list: D000964:Antimetabolites, Antineoplastic; D005938:Glucocorticoids; D003561:Cytarabine