A 3-year-old girl was transferred to our hospital with a history of progressively worsening visual acuity, difficulty walking and speaking, abdominal pain, and vomiting. She previously had been admitted to the emergency department of a local hospital with nonspecific abdominal pain, nonbilious, nonbloody vomiting, and frequent soft bowel movements for 3 days. The child was dehydrated and her complete blood cell count revealed a microcytic, hypochromic anemia. She was given fluids by mouth and was sent home with a prescription for ferrous sulfate solution and instructions for follow-up with her primary care physician. During the next 2 days her abdominal pain and vomiting continued. She also became lethargic, sometimes difficult to awaken, and developed an unsteady gait. The mother also noticed a deviation in the child's left eye and a deterioration in her hand-eye coordination. On subsequent evaluation at the local emergency department, she was more lethargic and had a heart rate of 60/min. Her laboratory findings included hemoglobin, 7.7 g/dL; mean corpuscular volume, 55.9 fL; red cell distribution width, 0.24; and a white blood cell count of 12.3×109/L, with 0.82 neutrophils. Cerebrospinal fluid analysis revealed a white blood cell count of 5.0×109/L, with 0.24 neutrophils and 0.62 lymphocytes; and a red blood cell count of 4.4×1012/L. Her serum ammonia level was 38 µmol/L; alanine aminotransferase, 53 U/L. Noncontrast computed tomography of the head showed normal findings. A blood lead concentration was also drawn at this time, but was sent to an outside laboratory for testing. The child was given 1 dose of ceftriaxone disodium, 100 mg/kg, and was transferred to our facility.