Much attention has been paid to the long-term toxic and carcinogenic effects of nicotine-containing substances, particularly tobacco. Although rare, acute ingestions of large amounts of nicotine can produce rapid and dramatic toxicity. We present a case of an ingestion of a nicotine sulfate solution by a 15-year-old boy resulting in hypoxia and irreversible encephalopathy. The diagnosis of acute nicotine toxicity potentially could be delayed due to the fact that nicotine and cotinine are so commonly found on drug screens that they are considered "normal variants."