The case of a five months-old child who received 44 mg/Kg of Fe-sorbitol I.M. by mistake is reported. That dose is about ten times the usual standard dosage. After an initial vague symptomatology, followed by transitory improvement, she developed a serious metabolic acidosis, renal and hepatic failure and generalized convulsions. The clinical picture could not be controlled by general supportive treatment, desferroxamine administration and exanguino-transfusion.