A 35-year-old Asian male presented with fever, jaundice, loose stools, palpitations, bilateral ankle swelling, shortness of breath, agitation and tremulousness following a brief illness with cough and cold. He was diagnosed to have thyrotoxicosis due to Graves’ disease 2 years back and had defaulted treatment with carbimazole and propranolol after 6 months. He did not give a history of previous hepatitis infections or blood transfusions. He had no exposure history for leptospirosis or other etiological agents of acute hepatitis such as intravenous drug abuse, risky sexual encounters or consumption of street food. He denied any hepatotoxic drug treatment, and had no history of joint pains or facial rashes. He had no past history of other chronic diseases. He consumed alcohol occasionally and the last alcohol consumption was about 2 months prior to his current presentation. On admission, he was febrile (101.6 °F) and had dyspnoea, deep icterus, tremulousness, sweaty skin and bilateral pitting ankle oedema. He had exophthalmos but no proptosis, lid lag or external opthalmoplegia. The thyroid gland was diffusely enlarged and there was no lymphadenopathy. He was conscious and rational with no focal neurological deficits. His Jugular venous pressure was elevated 8 cm above the sternal angle and the pulse rate was 120/min and irregularly irregular. The blood pressure was 150/70 mmHg. Examination of the lungs revealed end inspiratory bi-basal fine crepitations. The examination of abdomen was unremarkable except for mild tenderness over right hypochondrium. His laboratory investigation results were as follows; white cell count was 2.9 × 103/mL, platelets 59 × 103/mL, haemoglobin 11.1 g/dL, haematocrit 32.5 % suggesting bi-cytopenia and blood picture had no evidence of microangiopathic haemolytic anaemia. Urine full report was normal except for a trace of albumin. Serum sodium 137 mmol/L, potassium 3.9 mmol/L and creatinine 64 µmol/L (60–115). The liver functions; aspartate aminotransferase (AST) 71 U/L (0–40), alanine aminotransferase (ALT) 35 U/L (0–40), alkaline phospatase (ALP) 259 U/L (34–104), total bilirubin 72.9 µmol/L (1–23.9), direct bilirubin 39.2 µmol/L, γglutamyltransferase 149 U/L (7–50) suggesting cholestasis. His blood culture was sterile. Serum calcium 2.04 mmol/L (2.10–2.54) and magnesium 0.8 mmol/L (0.7–0.9). C-reactive protein 10.64 mg/L (0.00–5.00) and ESR 42 mm/1st h. His thyroid stimulating hormone (TSH) 0.01 mIU/L (0.35–4.94), free T4 5.14 ng/dL (0.70–1.48). Ultrasound scan of neck revealed defuse enlargement of thyroid gland with no nodules or enlarged cervical lymph nodes. TSH receptor antibodies were positive with a titre of 6.08 U/L (positive >1.75), suggesting thyrotoxicosis secondary to Graves’ diseases. He was negative for hepatitis A IgM, hepatitis B surface antigen (HBsAg), cytomegalo virus (CMV) IgM, Epstein barr (EBV) IgM, leptospirosis antibodies and anti-nuclear antibodies. He was not checked for Hepatitis E as it is extremely rare in Sri Lanka. The ECG showed atrial fibrillation with rapid ventricular response, chest radiography showed cardiomegaly with upper lobe diversion and 2D echocardiography revealed global cardiac dysfunction with ejection fraction of 50 %, suggesting possible thyrotoxic cardiomyopathy. Serial ECGs did not show evidence of dynamic ischemic changes and cardiac biomarkers were negative for an acute coronary event. He was treated as thyrotoxic crisis with atrial fibrillation leading to heart failure precipitated by lower respiratory tract infection in addition to deranged liver functions with no acute liver failure. Therefore the medical management included oral high dose carbimazole (45 mg/day), intravenous (iv) hydrocortisone 100 mg 8 hourly, iv cefuroxime 750 mg 8 hourly, and oral clarithromycin 500 mg twice daily and oral bisoprolol 5 mg twice daily. His clinical condition and liver biochemistry improved with total bilirubin coming down to 46.6 µmol/L, AST 27 U/L, ALT 23 U/L after 1 week of treatment for thyrotoxicosis. He was lost to follow up after 4 weeks and it was very sad to hear that he had succumbed to a fatal road traffic accident while attending to personal activities.