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Background Lead exposure remains a significant yet under-recognised public health concern in the UK, particularly among vulnerable paediatric populations. Its non-specific, multisystemic involvement and rare neurological presentations make recognition and timely treatment of lead poisoning especially challenging.Case presentation We report a case of a 6-year-old boy with autism spectrum disorder and pica presenting with new-onset refractory status epilepticus, unresponsive to standard antiepileptic therapy. Diagnostic evaluation demonstrated microcytic anaemia with basophilic stippling on blood film, diffuse cortical changes on MRI and markedly elevated blood lead levels, establishing the diagnosis of acute-on-chronic lead poisoning. Treatment with intravenous sodium calcium edetate and polyethylene glycol bowel irrigation led to progressive clinical improvement and seizure resolution. Serial measurements confirmed a declining lead burden, and the patient was discharged on oral chelation therapy.Conclusions This case highlights the importance of considering lead toxicity in unexplained encephalopathy or refractory seizures in children, with early recognition to prevent irreversible neurological sequelae.