Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing renal infection characterized by the presence of gas within the renal parenchyma and surrounding tissues. It commonly occurs in diabetic patients and carries a high mortality rate if not promptly treated. Based on the classification by Huang and Tseng (2000), EPN is categorized into four grades on CT imaging, ranging from localized to extensive extrarenal involvement. This classification plays a crucial role in determining the appropriate treatment strategy, including conservative medical management, percutaneous drainage, or surgical nephrectomy. Recent studies suggest that in mild cases of emphysematous pyelonephritis (EPN), a combination of antibiotics and percutaneous drainage may successfully preserve renal function. However, in severe cases with multiorgan failure, extensive necrosis, or disseminated infection, radical nephrectomy remains the life-saving intervention. This case represents a severe form of EPN with extension to the mediastinum, requiring emergency nephrectomy. It highlights the role of surgery in managing severe EPN, particularly when combined with VAC for postoperative wound management.

A 52-year-old female patient with a history of diabetes mellitus was admitted with septic shock. Computed tomography (CT) revealed right emphysematous pyelonephritis with gas and abscess formation extending to the mediastinum. The patient underwent emergency nephrectomy, VAC placement, and targeted antibiotic therapy.

After four days of intensive resuscitation, the patient recovered from shock, showed good postoperative progress, and had a clean surgical wound by the second week, which was closed by the third week.

Emphysematous pyelonephritis extending to the mediastinum is an extremely rare but life-threatening condition that requires early recognition and timely intervention...