Aorto‑esophageal fistulas (AEF) are rare, often fatal connections between the thoracic aorta and esophagus, arising from aortic disease, esophageal conditions, or iatrogenic causes. Case: A 76‑year‑old woman, treated for esophageal nutcracker syndrome with endoscopic injection of botox, developed chest pain and esophageal hemorrhage. Computed tomography (CT) confirmed an AEF from an aortic pseudoaneurysm. She succumbed to circulatory collapse before treatment. Discussion: Endoscopic botox injections are a rare cause of AEF. The diagnosis relies on imaging and endoscopy, with surgery often required. Teaching point: Aorto‑esophageal fistulas are rare, life‑threatening complications, particularly after iatrogenic procedures. Early diagnosis is crucial, but prognosis remains poor.