Methanol ingestion is an uncommon form of poisoning that can cause severe metabolic disturbances and potentially fatal and often irreversible organ/tissue damage. The diagnosis is sometimes elusive and requires a high index of suspicion. Because extent and irreversibility of the damage caused by formic acid is time sensitive, methanol poisoning should be recognised promptly so that it can be treated. Metabolic acidosis associated with an increased anion gap and osmolar gap is an important laboratory finding but is not always present. A case of severe methanol poisoning is presented that demonstrates the unique challenges in the diagnosis and management, and the lack of readiness of the health care system for such cases. We highlight some of the diagnostic difficulties associated with treating a patient with a reduced level of consciousness and severe metabolic acidosis. We also review the pitfalls of using laboratory tests to rule out alcohol ingestion and discuss the definitive management of methanol poisoning.