Alveolar hemorrhage associated with warfarin therapy: a case report and literature review Dogan Erdogan, Orhan Kocaman, Huseyin Oflaz & Taner Goren _ I stanbul Medical Faculty, _ I stanbul University, Capa, _ I stanbul, Turkey Received 10 June 2003; accepted in revised form 13 November 2003 Keywords: atrial fibrillation, diffuse alveolar hemorrhage, warfarin Abstract A 75-year-old man was admitted to our clinic with the complaints of palpitation, fever, severe dyspnea, dizziness and bloody sputum associated with coughing. Chest radiographs revealed that the lungs were bilaterally infiltrated. A high resolution computed tomographic study of the thorax disclosed diffuse alveolar hemorrhage, of which presence was proved by histopathological study of bronchoalveolar lavage material. The hemorrhage occured at 8th day of 5 mg daily warfarin therapy, which was given for frequent atrial fibrillation attacks was controlled by fresh frozen plasma and vitamin K. Alveolar hemorrhage is difficult to diagnose and has high mortality if the treatment was not started as soon as possible. This is the first report of alveolar hemorrhage caused by 5 mg daily warfarin therapy. We propose that the patient’s age, nutritional status, used drugs should be taken into consideration for true management of patients with atrial fibrillation. Abbreviations: DAH – diffuse alveolar hemorrhage; HRCT – high resolution computed tomography; INR – International Normalized Ratio; PT – Prothrombin time Introduction Oral anticoagulants are used for prevention of thrombo-embolic complications in atrial fibrilla- tion and other cardiovascular diseases. The most important adverse effect is hemorrhage. Alveolar hemorrhage is a rare complication that constituted a minor part of hemorrhage complications in pa- tients taking warfarin [1, 2]. Due to early treatment is life-saving, early diagnosis is very important. Case report The patient was a 75-year-old man who presented with complaints of fever, severe dyspnea, dizziness and bloody sputum associated with coughing. He had atrial fibrillation for 20 years. He had been taking aspirin and had used pindolol, quinidine, digoxin and metoprolol at different time intervals. Warfarin was added to the treatment by the dose of 15 mg for the first day and 5 mg for the rest days in January 2003. The International Normal- ized Ratio (INR) values controlled at 2, 3, 5 days of treatment were 1.9, 2.3, 2.5, respectively (nor- mal value of INR: <1.2). Eight days after the first dose of warfarin, the complaints began and pro- gressively increased. Two days after the start of complaints, the patient was admitted to a local hospital. The patient’s chest radiograph revealed bilateral alveolar infiltration. All medications were stopped and ampicillin and sulbactam, digoxin, furosemide was given to the patient for the treat- ment of congestive heart failure, pneumonia and The International Journal of Cardiovascular Imaging 20: 155–159, 2004. Ó 2004 Kluwer Academic Publishers. Printed in the Netherlands. 155