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A 45-year-old Taiwanese man with a history of poor controlled diabetes mellitus presented to our Emergency Department with fever, gross hematuria and left flank pain for 1 day. He had undergone extracorporeal shock wave lithotripsy for renal stone 2 days ago. On examination, he was febrile to 40.1°C with a pulse rate of 126 beat/min and a blood pressure of 91/54 mmHg. Marked knocking pain over left costovertebral angle was also noted. Laboratory tests showed the following: white blood cell count, 1740/μl; serum urea nitrogen, 34.8 mg/dl; creatinine, 1.7 mg/dl; arterial blood gas, pH 7.34; PCO2, 27.4 mmHg; PO2, 69 mmHg; bicarbonate, 21.1 mEq/l; lactate, 4.6 mmol/l. An abdominal radiograph disclosed some radioopaque lesions and abnormal gas distributed over regions where kidney, ureter and bladder were located (Figure 1, arrowhead). Renal sonography demonstrated dirty echoes accompanying posterior sonic shadowing. The computed tomography (CT) revealed an enlarged kidney as well as dilated pelvis and ureter, and even the bladder was filled with air (Figure 2, arrowheads). In addition, a small stone impacting at the ureterovesical junction is depicted in Figure 2B (arrow).

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