Very severe presentation of bilateral emphysematous pyelonephritis and cystitis. Air has extended into the retroperitoneum and systemic and portal veins. The renal involvement is severe and life-threatening, while the bladder involvement only indicates infection by a gas-forming organism (most commonly E. coli) but does not carry a grim prognosis. While emphysematous pyelonephritis is often managed with urgent nephrectomy, medical management was pursued in this case due to the bilateral involvement and poor outcomes expected with bilateral nephrectomies.