Fatal Accidental Intrathecal Injection of Vindesine

ABSTRACT: A 25‐year‐old woman being treated for non‐Hodgkin's lymphoma was accidentally given vindesine intrathecally. The error was recognized immediately and a spinal cord washing was performed through syringing with isotonic saline. However, the patient died 6 weeks later with increasing paralysis, which was followed by neurologic failure. The deceased was autopsied and the central nervous system was removed for a microscopic examination. The results showed microscopic lesions extending from the lumbar to the thoracic portion of the spinal cord, which included pseudocystic transformation of the cells, degeneration of myelin, and microhemorrhages. The brain was edematous and, in the cerebellum, the vermis showed a loss of granule and Purkinje cells. The authors compare this report on vindesine toxicity with cases in the literature involving vincristine. The treating physician admitted responsibility and was sentenced to both a fine and imprisonment.