Dabigatran: A Novel and Rare Cause of Diffuse Alveolar Hemorrhage (DAH)

Abstract

SESSION TITLE: Diffuse Lung Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 10:45 AM - 12:00 PM INTRODUCTION: DAH is a rare, life-threatening pathology characterized by intra-alveolar hemorrhage with a spectrum of clinical presentations. This syndrome includes hemoptysis, anemia, pulmonary infiltrates and hypoxemic respiratory failure. This case is a rare presentation of DAH secondary to a Novel Oral Anticoagulant (NOAC) in the absence of systemic vasculitis. CASE PRESENTATION: An 86 year old male with past medical history of atrial fibrillation on dabigatran and congestive heart failure, was found at home, hypoxemic and bradycardic to the emergency room. The patient was also noted to be anemic, requiring 2 units of PRBC and in acute renal failure. The patient met criteria for ARDS, including a chest X-ray suggestive of bilateral diffuse pulmonary infiltrates. He was maintained on low tidal volume, high PEEP ventilator support. Bronchoscopic lavage demonstrated progressively more hemorrhagic effluent, pathognomic for DAH. Investigations for vasculitis were negative. The thrombin time was noted to be elevated and hence Idaricizumab was started and hemodialysis initiated. The patient was successfully extubated in 7 days duration. DISCUSSION: GI bleeds and intracranial hemorrhages are known complications with dabigatran, however DAH is rare with only four other cases reported in our literature review1,2. Most of these cases were prior to the advent of Idarucizumab. Dabigatran toxicity may have occurred in this patient due to the occurrence of acute renal failure. Reversal agent may have a role in treating pulmonary hemorrhage and subsequent respiratory failure secondary to the use of NOACs. Interestingly, this patient also had no prior history of vasculitides or lung disease that would predispose the patient to DAH. CONCLUSIONS: To our knowledge this is the only case where resolution of ARDS secondary to DAH by Dabigatran use was achieved with the use of Idarucizumab, hemodialysis and lung protective ventilator strategy. This highlights the importance of considering DAH as a cause of ARDS especially in the setting of anticoagulation. Increasing use of NOACs requires physicians to be aware of the adverse effects and indications for using reversal agents, when available. Reference #1: Yokoi K, Isoda K, Kimura T, Adachi T. Diffuse Alveolar Hemorrhage Associated with Dabigatran. Intern Med. 2012;51(18):2667-2668 Reference #2: Kudo, K, Tanimoto, Y, Hisamoto, A, Ichihara, E, Tanimoto, M, Kiura, K. Dabigatran etexilate-induced alveolar hemorrhage. AJRS, 1(3): 247-250, 2012. DISCLOSURE: The following authors have nothing to disclose: Shyam Shankar, Prarthna Chandar, Hatem Desoky, Ishan Malhotra, Anand Kumar Rai, Mangalore Amith Shenoy, Benhoor Shamian, Pavel Gozenput, Roman Bernstein, Pavan Irukulla, Yizhak Kupfer No Product/Research Disclosure Information