CASE PRESENTATION: A 49-year-old male with compensated alcoholic cirrhosis presented with a painful, swollen left thumb, generalized abdominal pain with diarrhea, and lightheadedness. On examination, he was afebrile, hypotensive with a blood pressure of 60/40 mmHg, and hypoxemic, with an oxygen saturation of 88% while breathing ambient air. His left thumb was swollen, and a 1 cm purpuric eschar was identified on the lateral surface with no known antecedent trauma. Laboratory studies were notable for acute kidney injury (AKI), lactic acidosis, elevated transaminases, hyperbilirubinemia, and a marked leukocytosis with left shift. Despite aggressive volume resuscitation and initiation of broad spectrum antibiotics, he rapidly developed profound shock requiring administration of epinephrine, norepinephrine, and vasopressin; respiratory failure requiring intubation; anuria requiring continuous renal replacement therapy; and decompensated cirrhosis. Incision and drainage of the left thumb was performed, and cultures grew GAS; blood cultures remained sterile. Following debridement and narrowing of his antibiotics to ampicillin-sulbactam and clindamycin, his hypotension and AKI resolved, his tests of liver function improved, and he was successfully extubated and ultimately discharged home.