Alveolar Hemorrhage Associated with Rivaroxaban: A Case Series

Background: We present 4 cases of alveolar hemorrhage in patients receiving rivaroxaban. While bleeding is a common complication of rivaroxaban therapy reported by multiple case reports in the literature, this complication is not frequently reported. There were two cases of alveolar hemorrhage related to rivaroxaban found in our literature search. Alveolar hemorrhage is a potentially fatal complication and must be promptly recognized. Case Presentation: The electronic medical record was reviewed for patients with alveolar hemorrhage syndromes admitted to our hospital between July 1, 2014 and June 30, 2015. This data was cross referenced for patients received anticoagulant medications. Our series of patients included one patient with underlying Antiphospholipid Syndrome (APS) and systemic lupus erythematous, another patient with pulmonary malignancy and distant lung resection, a third patient with lymphangioleiomyomatosis, and a fourth patient with myelodysplastic syndrome. Rivaroxaban accounted for 13.6% of all cases of clinically significant pulmonary hemorrhage and drug related pulmonary hemorrhage accounted for half of cases. The rate of alveolar hemorrhage associated with Rivaroxaban in our institution was about 3 cases in 1000. Conclusions: We identified four cases of rivaroxaban associated alveolar hemorrhage. We encourage cautious use of rivaroxaban in patients with underlying lung conditions or factors that predispose to alveolar hemorrhage. Further research to clarify the risk of diffuse alveolar hemorrhage (DAH) in at-risk patients receiving oral anticoagulants is recommended.