Esophageal injuries in adults are most often iatrogenic, occurring after dilation of esophageal strictures. In this case, a 72 year-old female underwent esophageal dilations for a stricture resulting from radiation for breast and esophageal cancer. She then developed symptoms of pneumonia, followed by seizures and quadraparesis. Imaging revealed esophageal rupture with osteomyelitis, ventriculitis, intraventricular abscess and hydrocephalus from infectious dissemination. Iatrogenic esophageal rupture after dilation has a high mortality; the recommended initial evaluation is with a barium esophogram. Recent experience supports consideration of nonsurgical treatment, which can be as successful as surgical options.