Background: The mainstay of chelation therapy for pediatric patients who are symptomatic or have blood lead levels (BLL) greater than 69ug/dl is calcium disodium ethylenediaminetetraacetic acid (CaNa2EDTA) and British Anti-Lewisite (BAL). Furthermore, 2,3– Dimercaptosuccinic acid (Succimer) is approved for treatment of lead-poisoned children but recommended only for asymptomatic children with levels between 45–69ug/dl. Case report: A 20–month-old female was seen in clinic for pallor, vomiting and episodic fevers occurring during the previous week. She was also noted to have eaten paint chips over the last 2 weeks. Evaluation revealed a pale child with mild hypertension and a history of Glansmann’s Thrombocytopenia. A hemoglobin level was 5mg/dl and a BLL was 196mcg/ dl. The patient was immediately transferred to the emergency department. Vital signs were BP 140/90 HR 148, RR 32, Temperature 37.3 C. The child had no gastrointestinal or neurological symptoms. Initial laboratory values included an iron level of 205mcg/dl, normal basic metabolic panel and liver transaminases, WBC 18,000 RBC 4.18, Hgb 5.6gm/dl, Hct 20.4%, MCV 49, MCH 13.4, Platelets 514,000, Alk Phos 163, Albumin 4.3. An abdominal x-ray showed radiopaque material throughout the small intestines. Whole bowel irrigation (WBI) was started at 500ml/hr. After 18 hours of WBI and persistent intestinal radiopaque material, treatment with Succimer was initiated at 100mg twice a day and increased to 200mg every 8 hours on day 2. One unit of packed RBCs was given on day 2. The patient remained asymptomatic and was discharged on day 5 with a BLL of 107ug/dl for outpatient treatment with Succimer. BLLs decreased from 196ug/dl to 13ug/dl over a 2-month period. Follow-up confirmed the patient remained asymptomatic. Conclusion: We report a case of one of the highest BLLs reported in the literature with minimal symptoms successfully treated with Succimer. Long-term neuropsychological and cognitive effects cannot be predicted.