We present the fatal case of an infant intoxicated with Tramadol detected in bone after an interval of twenty-eight months post mortem, after study ordered by the prosecutor for similar symptoms in a surviving brother. Intoxications occurred during their hospitalization for an idiopathic, convulsive and refractory syndrome to treatment, in the context of a Factitious Disorder imposed on another. We analyze mode of presentation for the case, the importance of health team in early detection and forensic approach for final diagnosis.