Background: Salicylate toxicity can manifest with delayed symptoms that complicate prompt diagnosis and intervention. Although delayed peak concentrations after ingestion have been documented, reports of patients remaining asymptomatic for more than 20 hours are uncommon. Case presentation: We present the case of a 2-year-old female who ingested a highly toxic dose of 463 mg/kg of enteric-coated aspirin and remained asymptomatic for the initial 20 hours. Subsequently, she developed severe symptoms of increased respiratory effort and altered mental status with laboratory confirming combined respiratory alkalosis and anion-gap metabolic acidosis. Patient was initially managed through sodium bicarbonate alkalization and was later managed through hemodynamic dialysis due to persistence of symptoms. Conclusion: This case report underscoring the importance of vigilant monitoring and prompt intervention in patients with salicylate ingestion and possibility of delayed symptoms following asymptomatic period.

Keywords: salicylate toxicity, aspirin toxicity, pediatric, entirc-coated aspirin.