A 42-year-old woman with uncontrolled diabetes mellitus presented to the emergency department with fever, nausea, dysuria, and left flank pain. Physical examination revealed knocking tenderness on the left costovertebral angle. Laboratory results revealed leukocytosis, diabetic ketoacidosis, and pyuria. An abdominal radiograph showed air in the left renal fossa and ureter ( Figure 1). Computed tomography (CT) demonstrated left emphysematous pyelonephritis (EPN) with air collections in the left kidney, perinephric space and ureter, and a calculus at the ureterovesical junction (Figures 2 and 3). The patient was treated with resuscitation, glycemic control, antibiotic therapy, and a percutaneous drainage. After stabilization of the general condition, subsequent nephroureterectomy was performed. The cultures of pus and urine yielded Escherichia coli.

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