Idiopathic esophageal ulcerations (IEUs) associated with human immunodeficiency virus (HIV) infection are now recognized as an important cause of esophageal disease in this population. We report one case of IEU complicated with a fistula to the bronchial tree. Given his variable appearance, which may mimic other causes of esophageal ulceration and the high response rate to oral corticosteroid therapy, all HIV infected patients with esophageal ulceration should undergo endoscopy with biopsy to obtain a definitive diagnosis. We review the literature about the etiology, pathogenesis, management and treatment of the IEU.