Introduction: The authors report the first known adult case of daunomycin inadvertently administered directly into the human central nervous system and the neurological manifestations and therapeutic interventions that followed.
Methods: A 53 year old man presented to the hospital for his second cycle of consolidation therapy for Acute Promyelocytic Leukemia t(15;17), including intrathecal administration of chemotherapy. Over the next several hours, the patient complained of bilateral lower extremity pain and paresthesias. He subsequently developed headache and a left CN III palsy. During this time, it was discovered that he had inadvertently received intrathecal daunomycin instead of methotrexate. The neurosurgical service was consulted. An immediate lumbar drain (LD) was placed for continuous cerebrospinal fluid (CSF) drainage, and the patient was transferred to the neurosurgical intensive care unit.
Results: The patient experienced a decline in mental status requiring intubation and a placement of an external ventricular drain (EVD) on day 2. During the subsequent days, the patient developed bilateral lower extremity paraparesis, which progressed in an ascending manner. An MRI of his lumbosacral spinal cord demonstrated thickening and perimedullar enhancement of the conus medullaris and cauda equina (Figure 1). At 10 days, an MRI of the brain showed diffuse leptomeningeal enhancement of skull base and anterior interhemispheric fissure (Figure 2). The patient continued to experience elevated intracranial pressure (ICP) and required placement of a ventriculo-peritoneal (VP) shunt on day 14. The patient’s clinical status continued to decline and eighteen days after intrathecal administration of daunomycin, all cranial nerve functions were lost. Due to the patient’s poor neurological examination, the family chose to allow natural death.
Conclusions: To date, this is the first documented case of inadvertent intrathecal daunomycin administration in an adult patient. Our report describes the time course, neurologic manifestations, and radiographic findings associated with daunomycin neurotoxicity. It is unknown whether earlier recognition, leading to the more prompt initiation of therapy, would have improved the patient’s outcome.
Patient Care: This case report will improve patient care by allowing health care providers to recognize the need for vigilance when delivering intrathecal agents and the urgency of neurosurgical intervention in the setting of intrathecal administration of neurotoxic agents.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the neurological sequelae of intrathecal administration of daunomycin, and 2) Discuss, in small groups, the neurosurgical interventions available for emergent access and evacuation of agents toxic to the central nervous system.