A 17-year-old girl presented with one week of fatigue, dyspnea and chest pain. Initial vitals were temperature 36 °C, heart rate 113, blood pressure 127/78, respiratory rate 56, and oxygen saturation 95%. Initial exam was notable for mydriasis and tachypnea. Laboratory tests were significant for bicarbonate level <5 mmol/L, anion gap >25 mmol/L, lactate 2.2 mmol/L, and creatinine 0.8 mg/dL. Routine toxicology screen, including salicylates, was negative. Two hours after arrival, she became encephalopathic, with a normal brain computed tomographic scan and lumbar puncture, followed by a tonic-clonic seizure and was intubated.