CASE PRESENTATION: A 44-year-old woman with a history of alcoholic pancreatitis,presented to the Emergency Department with epigastric pain and vomiting of 3 days duration after binge drinking with vodka. Vital signs were remarkable for temperature of 92.90F and respiratory rate of 35. She took no medications. Clinical examination was remarkable for Kussmaul’s breathing, mid-epigastric tenderness, hepatomegaly and warm extremities. Laboratory studies revealed WBC 19.2/mm3, Hb 5.8g/dL, PLT 107/mm3,pH 6.88, LA>15mmol/L, slightly elevated lipase and moderate transaminitis. She received 4 liters of normal saline, 2 units of packed red blood cells and antibiotics. LA decreased to 9.9mmol/L. TD was suspected and 500mg intravenous thiamine was given. LA levels subsequently decreased dramatically.