Warfarin-induced diffuse alveolar hemorrhage: Case report and a review of the literature

Abstract

Diffuse alveolar hemorrhage (DAH) refers to the intra-alveolar accumulation of blood originating from the pulmonary microvasculature. This life-threatening condition is a medical emergency as patients often develop acute respiratory failure requiring invasive mechanical ventilation. This mandates for an early diagnosis with prompt and aggressive management strategies. A host of clinical disorders are known to cause DAH; however, warfarin-induced alveolar hemorrhage is a distinct clinical rarity. A search of the literature reveals few reports documenting this entity. A 27-year-old male presented with complaints of recent-onset hemoptysis and dyspnea. One month back, he was diagnosed with lower-limb deep-venous thrombosis and pulmonary embolism. He had been taking oral anticoagulants irregularly since then without monitoring of prothrombin time. Chest radiograph, done on presentation, revealed bilateral upper-lobe infiltrates, whereas computed tomography of the chest was suggestive of bilateral upper-lobe ground-glass opacities. Serial bronchoscopic alveolar lavage yielded samples which became progressively bloodier, whereas cytological evaluation of the sample revealed numerous alveolar macrophages with intracytoplasmic hemosiderin. A diagnosis of DAH due to warfarin was made, and the patient was administered Vitamin K followed by infusion of fresh frozen plasma. There was a marked clinical recovery, and the patient has been asymptomatic since then.

Vitamin K: a potential missing link in critical illness–a scoping review

“…Vitamin K deficiency increases the risk of microvascular bleeding or diffuse alveolar hemorrhage (DAH) in ICU patients. This bleeding, involving blood accumulation in lung tissue, has been linked to vitamin K deficiency caused by coumarin anticoagulants [ 51 – 53 ]. Iron accumulation during DAH causes oxidative stress and inflammation, contributing to the pathophysiology of fibrotic lung diseases [ 45 , 47 , 54 – 57 ].…”