Introduction: A 31-year-old male patient with a history of Grave’s disease was transferred from an outside hospital for management of worsening shortness of breath, nausea, diarrhea, weight loss, and sweating over the course of a month. His physical exam at admission was notable for a low-grade temperature and atrial fibrillation with rapid ventricular response. Laboratory testing revealed evidence of uncontrolled hyperthyroidism with a TSH of 0.17 and T4 5.81. Liver function tests were notable for an AST of 243 U/L, ALT of 333 U/L, total bilirubin of 3.0 mg/dL, and an INR of 3.3. He had no known prior history of liver disease. During the initial 24 hours of his hospitalization, he developed progressive signs of acute liver failure with a worsening coagulopathy and encephalopathy requiring intubation. An evaluation for alternative causes of ALF was negative; therefore, an urgent transplant evaluation was initiated and the patient was empirically started on N-acetylcysteine. Due to the time course of his decompensation, it was felt that he needed emergent control of his hyperthyroid state. He was started on hydrocortisone and propranolol for the thyroid storm and taken for an emergent thyroidectomy. Post-operatively, his transaminases peaked at 9,780/4,342 (AST/ALT) and a total bilirubin of 9.8 mg/dL. His mental status improved and he was liberated from the ventilator. His hepatic function continued to improve and a transplant was avoided. He was successfully discharged home on hospital day 20. This case illustrates the complexity of thyroid storm complicated by acute liver failure and the value of a multidisciplinary team approach to management. Although the pathophysiology of liver disease due to thyroid disease is poorly understood, the major hypothesis seems to be that of thyroid hormone-induced increases in mitochondrial oxygenation without a compensatory increase in blood flow. Uncontrolled hyperthyroidism can lead to elevated transaminases and eventual cirrhosis. Cases of acute liver failure are described with centrizonal necrosis, typically in the setting of an acute stress, or trigger, such as sepsis or surgery. Both thyroid storm and fulminant liver failure are complex, life-threatening diagnoses, and each diagnosis in isolation carries a significant mortality rate, while the combined diagnoses can be devastating. Quick recognition and surgical treatment in this case resulted in a successful outcome.