[Thioridazine intoxication of therapeutic error as the cause of death of a three-year girl].

Intoxication with drugs and xenobiotics in children, particularly under the age of 7 years, represents a serious diagnostic and therapeutic challenge considering the relatively immature enzymatic detoxication systems, greater susceptibility to organ lesions, easily destabilized homeostasis (including water-electrolyte balance) and limited compensatory mechanisms in acidosis or alkalosis. We present the case of a 3-year-old girl, who died 30 hours after admission to hospital, with suspicion of ingestion of two or three 100-mg tablets of thioridazine. The medical documentation and results of autopsy are in favor of acute cardiopulmonary failure caused by extensive cerebral and pulmonary edema as a complication of "water poisoning" i.e. acute hypotonic overhydration of the child.