This is a case of a 63 year old African American male being evaluated for severe sepsis from healthcare associated pneumonia. He has history of liver cirrhosis from hepatitis C, end stage renal disease, combined liver and kidney transplantation in 2007 and was on immunosuppressant (mycophenolate mofetil, and cyclosporine), prednisone, and trimethoprim-sulfamethoxazole. He was admitted to the MICU and commenced on broad spectrum antibiotics. Cyclosporine was held due to AKI. On day 8, he developed diffuse abdominal pain, diarrhea consisting of dark stools, and one episode of coffee ground emesis. On physical exam, abdomen was non-distended with diffuse tenderness but no peritoneal signs. Labs revealed serum creatinine of 1.65 mg/dl. Patient exhibited mild leukocytosis to 13,300/uL. CT abdomen-pelvis revealed non-specific thickening of the esophagus. Naso-gastric tube returned non-bloody bilious gastric contents. Upper endoscopy revealed circumferential esophageal necrosis extending to mid esophagus. There was luminal narrowing in the distal esophagus. Biopsies taken were notable for “extensive necrotic debris with ulcerative acute esophagitis”. Patient was kept NPO, commenced on IV pantoprazole and sucralfate. Patient was treated with bowel rest, two weeks of antibiotics and four weeks of antifungals. Abdominal pain, loose stools and melena resolved. Repeat upper endoscopy one month later revealed complete resolution of esophageal necrosis. Acute esophageal necrosis(AEN) also known as ‘black esophagus’ is a rare disease with incidence of 0.01% to 0.2% in endoscopic studies. Mortality specific to AEN is 6% and is related to complications such as perforation. It presents with acute upper GI bleed in 90% of cases. Diagnosis is by endoscopic visualization of the characteristic esophageal features and this can be confirmed by pathology result of biopsy specimen but not required. Treatment consists of treating the underlying condition, restoration of normal blood pressure, acid suppression therapy with IV PPI, H2 blocker with or without sucralfate, bowel rest for a few days with total parenteral nutrition (TPN). Complete mucosal healing can be seen as early as 1 week. Complications include stenosis, superinfection and perforation. AEN is a rare disease entity that can be diagnosed only endoscopically and requires a high index of suspicion for early diagnosis and prompt treatment. Further research is needed to understand how to prevent it.Figure 1Figure 2Figure 3