<p>Esophageal injury is a rare and life-threatening event. Esophageal perforation can rapidly contaminate the neck, mediastinum, pleural cavity, or abdominal cavity, leading to sepsis or septic shock. Its high complication and mortality rates are often associated with adjacent organ damage and/or delays in diagnosis or definitive treatment. We present a case of a patient who developed esophago pleural fistula(EPF) due to traumatic fall.</p><p>A 64-year-old man presented with respiratory sepsis after a traumatic fall. Imaging demonstrated a massive pleural effusion. The initial lung CT did not reveal any abnormal communication between the esophagus and the pleural cavity. Metagenomic next-generation sequencing (mNGS) of pleural fluid revealed a microbial profile overwhelmingly composed of typical oropharyngeal flora, which was highly suggestive of an aero-digestive fistula. Subsequent gastroscopy and contrast examination confirmed a fistula between the distal esophagus and the left pleural cavity through a ruptured diaphragm. The patient underwent conservative treatment. A persistent effusion with a history of blunt thoracoabdominal trauma may raise suspicion for EPF, which, if not diagnosed promptly, may result in significant morbidity. This case provides new insights for diagnosing EPF following blunt trauma. Interpreting key subtle clues in pleural fluid analysis and imaging can lead to a timely diagnosis and thus improves morbidity and mortality of EPF.</p>