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Necrotising pyelonephritis is an uncommon but severe renal infection that may lead to septic shock and thrombotic complications. Cardiac arrhythmias are recognised in sepsis; however, presentation with supraventricular tachycardia (SVT) is unusual and may obscure the underlying diagnosis. A previously healthy woman in her late teens presented with fever, flank pain and hypotension associated with SVT unresponsive to vagal manoeuvres and adenosine. Sinus rhythm was restored following fluid resuscitation. Further evaluation revealed septic shock due to right-sided necrotising pyelonephritis complicated by right renal vein thrombosis, with blood and urine cultures growing Escherichia coli Echocardiography demonstrated transient left ventricular systolic dysfunction consistent with sepsis-induced myocardial dysfunction. She was managed with early haemodynamic optimisation, broad-spectrum antibiotics, ureteric stenting and anticoagulation, resulting in full recovery. This case highlights that SVT may rarely represent a presenting feature of septic shock and underscores the importance of prompt source control and multidisciplinary management.