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A 78-year-old cholecystectomized female Caucasian patient without comorbidities presented with 3 days of abdominal band-like pain and fever, and started treatment for presumed acute pyelonephritis. Despite antibiotic therapy, the patient developed dyspnea, hypotension, and clinical and laboratory signs of sepsis. She was admitted to the Hospital de Clínicas de Porto Alegre with septic shock, without an initially set focus. There was clinical deterioration characterized by acute respiratory failure and acute renal failure (ARF), and supportive measures were initiated. Imaging tests of the chest and abdomen were performed in order to assess the consequences of septic shock, among them, mesenteric ischemia. A computed tomography (CT) of the abdomen with intravenous injection of iodinated contrast medium showed reversal of renal nephrogram, characterized by the absence of cortical uptake of both kidneys, and highlight only of the renal medullary (Figures 1 and 2). The spleen showed ischemic areas. There was no sign of mesenteric ischemia or othe