When Source Control Is Not Enough: Bilateral Adrenal Hemorrhage After Group A Streptococcal Necrotizing Soft Tissue Infection

Refractory septic shock following adequate surgical source control presents a major clinical challenge. While persistent vasopressor dependence in necrotizing soft tissue infections (NSTI) is frequently attributed to ongoing tissue necrosis or overwhelming cytokine release, acute primary adrenal failure due to Waterhouse-Friderichsen Syndrome (WFS) represents an underrecognized, reversible etiology. We report a 41-year-old male who developed fulminant right upper extremity Group A Streptococcus (GAS) necrotizing fasciitis requiring emergent forequarter amputation. Despite definitive source control, targeted antitoxin antimicrobial therapy, and guideline-directed resuscitation, he experienced persistent vasopressor-dependent shock. On postoperative day 5, CT imaging revealed new-onset bilateral adrenal hemorrhage. The initiation of stress-dose hydrocortisone led to rapid hemodynamic stabilization and successful recovery. Surgeons must maintain a high index of suspicion for acute adrenal crisis in postoperative ICU patients with refractory shock despite source control, rather than solely driven by ongoing sepsis.