28 year old compliant man with a history of type I diabetes mellitus and primary hypothyroidism, presented to the ER for a two day history of fatigue, nausea, vomiting and abdominal pain. On physical exam, patient was drowsy with a dry skin and normal temperature. Kussmaul respirations were noted and HR was 120bpm. Laboratory workup showed glucose of 747, positive serum acetone, creatinine 4, and metabolic acidosis with anion gap of 64. ABG revealed the following: pH 7.071, PaO 2 117.3, PaCO 2 20, and HCO 3 5.8 meq/L. Appropriate treatment for DKA was initiated and despite adequate fluid resuscitation, patient remained tachycardic. EKG showed sinus tachycardia. Upon further questioning the patient, he reported those 2 weeks prior, he started experiencing erectile dysfunction and decided on his own to increase his dose of levothyroxine from 300 to 600 mcg per day. Thyroid panel was ordered and it showed a TSH of 0.014 and FT4 of 3.1 so beta blocker was started. Twelve hours later, his DKA resolved as well as his acute renal failure and he became hemodynamically stable. Conclusion: Thyroid storm and DKA are both potentially fatal especially that DKA may obscure the typical clinical presentation of thyrotoxicosis. Prognosis varies depending on whether or not these conditions are detected early and treated sufficiently. Persistent tachycardia following correction of dehydration in aseptic patients with DKA should raise the possibility of thyrotoxicosis especially for those known to have a thyroid disease. Diabetic patients taking thyroid hormones should be made aware of the complications that may result from excess doses.