Background: Emphysematous pyelonephritis (EP) is a rare but life-threatening condition of the upper urinary tract, characterized by the presence of gas in the renal parenchyma and perirenal space. The vast majority of patients with EP (90%) are known to have diabetes, with Escherichia coli being the most common causative pathogen.
Case report: We present a case of fatal bilateral EP in a patient with diabetes, with an unusual radiological finding of gas around the spinal cord and in the psoas muscle, with renal parenchymal sparing. Our case serves as an important reminder of this life threatening entity in diabetic patients, which is not well recognized by clinicians because of its rarity.