Emphysematous pyelonephritis is a life-threatening, urologic emergency. We present the case of a 54-yearold female who was found to have a large volume of air in her renal vein and inferior vena cava from severe emphysematous pyelonephritis. In this case report, the medical and operative management of this patient are reviewed, and the literature on the management of emphysematous pyelonephritis is summarized.