Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the kidney, characterized by gas within the renal parenchyma. It is strongly associated with diabetes mellitus and ureteric obstruction. We describe the case of a young female with severe EPN and gas extending diffusely throughout the abdomen. We demonstrate the progression of her infection on CT images from initial admission to percutaneous drainage (PCD) of a large air-fluid collection and then to a period of non-resolution that required elective nephrectomy. Although emergency nephrectomy was historically indicated in EPN, image-guided PCD is emerging as an effective nephron-sparing intervention when combined with supportive care and antibiotic therapy. This can be followed by elective nephrectomy if indicated.