Pipazethate HCl is a non-narcotic oral antitussive agent that act centrally on the medullary cough centre [1], with a chemical composition of C₂₁H₂₅N₃O₃S HCl [2]. It is less frequently used nowadays, the most common side effects of this drug include drowsiness, nausea, vomiting, restlessness, insomnia or urticarial [3]. Drug toxicity is rarely reported in the literature and it includes neurological, respiratory and cardiovascular symptoms [4]. A high index of suspicion and prompt treatment are required to improve patient prognosis [5-7].

A 3-years-old male child with no past medical history or surgical history, presented to our medical facility after ingestion of about 300 mg of Pipazethate HCl (Selgon, Eipico Egypt, Egypt) syrup with a disturbed level of consciousness with a Glasgow coma scale of E3M5V3, shocked with a blood pressure of 60/30 mmHg, distressed with a respiratory rate of 40 cycles per minute and bradycardia, his electrocardiogram (ECG) showed junctional rhythm at 35 beats per minute. The patient was intubated, mechanically ventilated, resuscitated, a transcutaneous pacing was placed and transferred to a critical care unit. His labs were unremarkable except for high anion gap metabolic acidosis. He received supportive treatment in the form of Gastric decontamination, IV fluids, vasopressors, IV NaHCO3. A follow-up ECG showed normal sinus rhythm with ventricular bigeminy at a rate of 80 beats/minute. A 2^nd follow-up ECG showed runs of non sustained ventricular tachycardia alternating with normal sinus rhythm. After that, the patient developed Torsade de pointes. He was managed using IV bolus of magnesium sulphate (MgSO₄) and maintained on lidocaine infusion with no further attacks of ventricular tachycardia and continued the supportive measures. On the next day, the child was hemodynamically stable and extubated, kept under observation for two days with gradual improvement of conscious level and was discharged on the 3^rd day of admission after total clinical resolution of all symptoms.

Pipazethate HCl is a non-narcotic oral antitussive agent that acts centrally on the medullary cough centre [2]. The most common side effects related to Pipazethate are drowsiness, nausea, vomiting, restlessness, insomnia and urticarial [3]. Manifestations of toxicity of this drug include a wide variety of symptoms such as neurological, respiratory, metabolic and cardiovascular symptoms [4]. Neurological symptoms include somnolence, agitation, convulsive seizures and coma. Respiratory symptoms such as Kussmaul breathing, respiratory depression and apnea. Neurological and respiratory manifestations are usually related to the central depressive effect of the drug and subsequent death is usually related to serious hypoxia [5]. While cardiovascular toxic manifestations are related to the fact that Pipazethate HCl has a quinidine-like action which is the main cause of cardiac dysrhythmias related to the toxicity of the drug in the form of prolongation of QT interval and predisposition to ventricular tachycardia and Torsade de pointes or less frequently bradycardia [6]. Metabolic and laboratory findings include severe acidosis, hyperglycemia, glucosuria and hyperkalemia [4]. Prompt diagnosis and urgent management are mandatory to prevent the lethality of the drug [5,7].

The use of centrally acting antitussives is markedly decreased nowadays. Pipazethate HCl toxicity is extremely rare and to our knowledge, this is the 5^th case that ever reported in the literature about its toxicity.

The authors would like to thank the following doctors: Ahmed El Degheidy, Khaled Mohamed Ali, Nada Hafez and Islam Kotb Critical Care Medicine specialists and Ola El Gebaly Cardiology Specialist for their effort in managing the patient.