FATALITY RESULTING FROM INTRAVENTRICULAR VINCRISTINE ADMINISTRATION

Background: Inadvertent intrathecal administration of vincristine has been reported and is uniformly fatal except in two of three cases trea ted with spinal fluid exchange. We report a case of inadvertent direct intraventricular vincristine administration. Case Report: A 59-year-o ld woman developed acute lymphocytic leukemia with meningeal involveme nt and was being treated with intraventricular cytarabine (beta-cytosi ne arabinoside, Ara-C) injected via an Ommaya reservoir, intravenous ( IV) vincristine, prednisone, and IV daunorubicin. The vincristine (2 m g in 10 mL diluent) was inadvertently injected into her Ommaya reservo ir. Within 10 minutes, the error was realized. Despite optimal care, n ausea and vomiting developed the first night, followed sequentially by coarse tremor, disorientation, horizontal nystagmus, and stupor. Her mental status waxed and waned until day 9, at which time she became re sponsive only to noxious stimuli. By day 11, she was deeply comatose a nd on day 40 she died without regaining any neurological function. Con clusion: Despite aggressive and immediate therapy, intraventricular vi ncristine infusion produced neurologic toxicity, with progressive loss of mental function, followed by coma and death. Systems need to be de veloped to prevent inadvertent central nervous system administrations.