BACKGROUND: The atypical antipsychotic quetiapine is a widely prescribed medication with many well-described effects in overdose. Death, however, is rarely reported. We present a patient who developed bowel infarction and subsequently died following a large ingestion of quetiapine. We believe this to be the first such case reported. CASE: A 53-year-old male was found with altered mental status at home by his wife. He stated that he had taken all of his quetiapine (18 gm) in a suicide attempt. By the time paramedics arrived he was obtunded and required intubation. Upon arrival in the ED his blood pressure and temperature were normal. His ECG revealed HR 104/min, QRS 108 ms, and QTc 526 ms. He had normal glucose, basic metabolic panel, lactate, chest x-ray, and head CT. His urine drug screen for drugs of abuse was positive for benzodiazepines. Charcoal was administered through an OG tube, and whole bowel irrigation was begun. In the first 6 hours after the ingestion he developed hypotension requiring fluid and pressors. During the next 6 hours, he developed metabolic acidosis with a lactate of 8.5mmol/L. An abdominal CT scan revealed likely bowel infarction. He had a partial bowel resection shortly thereafter and his hospital course included 3 additional bowel surgeries. He unexpectedly aspirated charcoal during re-intubation 5 days after he received the charcoal in the ED. He expired on hospital day 16 with multi-organ failure. DISCUSSION: This patient displayed some of the common side effects of quetiapine, including altered mental status, tachycardia, QTc prolongation, and hypotension. He also developed intestinal infarction, a result previously not described in quetiapine overdose. He had no previous evidence of mesenteric ischemia, or vascular disease of any kind. Of note also in this case is the charcoal aspiration 5 days after administration. Conclusion: Quetiapine overdose can result in cardiovascular compromise severe enough to cause bowel infarction. Moreover, the risk of charcoal aspiration persists for many days, especially for ingestions that affect gastrointestinal function.