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A 62-year-old obese female with no known chronic medical problems presented to the emergency department complaining of increasing fatigue and generalized weakness over several weeks duration. She appeared toxic with tachycardia, tachypnea, and hypotension. Initial laboratory tests revealed white blood cell count of 23,000/μL with a left shift, sodium of 151 mmol/L, potassium of 5.3 mmol/L, bicarbonate of 6 mmol/L, chloride of 121 mmol/L, creatinine of 1.8 mg/dL, glucose of 700 mg/dL, and positive serum ketones. Her urine was grossly bloody, and urinalysis revealed greater than 100 white blood cells and 100 bacteria per high-power field. Due to impending respiratory failure, she was intubated and transferred to the intensive care unit with a diagnosis of diabetic hyperosmolar non-ketotic acidosis and sepsis from pyelonephritis.On examination, the patient was noted to grimace with abdominal palpation. Bedside abdominal ultrasound was obtained and suggested a left renal mass, but imaging was suboptimal. After stabilization with intravenous (IV) fluids, insulin, and antibiotics, a computed tomography (CT) scan of abdomen and pelvis with IV contrast was ordered and showed bilateral RVTs and a 7.3 × 4 × 4 cm heterogeneously enhancing solid mass with cystic components of the left kidney (Figure-1).