The Grocery Store Blues: Recognizing a Toxic Syndrome When History Fails

Altered mental status and decreased respiratory effort are potentially life-threatening symptoms that encompass a wide variety of etiologies including toxic ingestions. We report a case of methadone toxicity in a 34-month-old girl with Noonan syndrome who presented to the emergency department with episodes of altered mental status, bradypnea/apnea, and miosis. Initial history and comprehensive evaluation including urine drug screen did not reveal a diagnosis; however, response to naloxone indicated that her presentation was likely caused by opioid toxicity. This diagnosis was later confirmed with toxicologic testing, which demonstrated an elevated serum methadone concentration. This case illustrates the need for a high index of suspicion for ingestions in children presenting with altered mental status and respiratory depression without an obvious pulmonary or central nervous system cause as well as the importance of recognizing a toxidrome, despite a lack of history of a toxic exposure.