Illustrative CasesHard as Iron A Case of Delayed Presentation of Severe Iron Toxicity With Diagnostic and Treatment DilemmasRickner, Shannon S. MD∗; Feng, Sing-Yi MD, FAAP†Author Information From the ∗Division of Medical Toxicology, Department of Emergency Medicine †Division of Medical Toxicology, Department of Emergency Medicine, Parkland Memorial Health & Hospital System, University of Texas Southwestern Medical Center, Dallas, TX. Disclosure: The authors declare no conflict of interest. Reprints: Shannon S. Rickner, MD, Division of Medical Toxicology, 5323 Harry Hines Blvd, Dallas, TX 75390 (e-mail: [email protected]). Pediatric Emergency Care: May 2021 - Volume 37 - Issue 5 - p e269-e271 doi: 10.1097/PEC.0000000000002430 Buy Metrics Abstract Cases of severe iron toxicity have become increasingly rare; most cases are intentional ingestions by late adolescents and adults who present within 12 hours of ingestion. We present a case of an adolescent girl with metabolic acidosis, hypoglycemia, obtundation, and liver and renal failure of undifferentiated etiology who was eventually discovered to have overdosed on ferrous sulfate tablets 4 days before arrival. The diagnosis was made because the patient had an elevated transferrin concentration in the setting of a minimally elevated serum iron concentration and faint radio-opacities on abdominal plain film imaging. This case presents many diagnostic challenges and treatment dilemmas and is a rare report of survival in delayed presentation of severe toxicity. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.