A 46-year-old man with poorly controlled type 2 diabetes mellitus and hepatocellular carcinoma with hepatitis B virus infection presented with general weakness and oliguria of 3-day duration. Serum creatinine was 6.6 mg/dL, blood urea nitrogen 112 mg/dL, leukocytes 37,600/μL, platelets 5,000/μL, and glycated hemoglobin 11.8%. He developed hypotension and metabolic acidosis. Continuous renal replacement therapy and inotropics were immediately initiated. Plain abdomen (Fig. 1A), and computer tomography (Fig. 1B and 1C, arrows) without contrast revealed extensive intraparenchymal and perinephric air collections in both enlarged kidneys that looked like wood charcoal, as well as air tracking in both proximal ureters. He was diagnosed with bilateral emphysematous pyelonephritis (EPN) and received intravenous meropenem, empirically. However, bilateral percutaneous drainage could not be performed due to hemodynamic instability. Escherichia coli was isolated in blood and urine cultures. He died of septic shock 3 days after admission.