In children, the most common cause of an elevated anion gap (AG) with ketonemia, ketonuria, hyperglycemia, and glycosuria is diabetic ketoacidosis. However, when the clinical history is not clear, other causes must be considered. A 9-month-old girl was transferred to our pediatric intensive care unit (PICU) because of severe metabolic acidosis. On admission, she presented with Kussmaul breathing, tachycardia, irritability, and fever. Blood gasses revealed metabolic acidosis with superimposed respiratory alkalosis and elevated AG. Fluid replacement and bicarbonate for urine alkalinization were started. Ketonemia, acidic urine with glycosuria, ketonuria, and high blood glucose prompted an insulin infusion. Measurement of plasma salicylate confirmed toxic levels. When confronted, the parents admitted to accidentally preparing the child's bottle with water containing salicylic acid 1000 mg. Although the incidence of salicylate intoxication has declined, it remains an important cause of pediatric morbidity and mortality.