Dear Sir: Diffuse alveolar hemorrhage (DAH) is a rare but serious event, with 50% mortality in patients who require mechanical ventilation. Recently, local or systemic administration of recombinant activated factor VII (rVIIa) has been successfully used for treatment of DAH [1, 2]. A 53-year-old man without any medical history was admitted to the emergency room with cholestatic jaundice associated with a flu-like syndrome evolving for 48 h. Laboratory data showed severe cholestasis and hepatic cytolysis, acute renal failure, and isolated thrombopenia (19 G/l), without coagulation abnormality. Computed tomography (CT) scan revealed multiple disseminated pulmonary micronodules mainly in the right lung and a small left pleural effusion. No radiologic explanation was found for the cholestasis. Shortly thereafter, acute respiratory failure occurred secondary to a DAH. The patient was intubated because of severe hypoxemia (Fig. 1) leading to cardiac arrest. External cardiac massage and epinephrin injections allowed restoration of sinusal rhythm. At FiO2 = 1, pH was 7.0, arterial lactate was 13 mmol/l, and PaO2 was 37 mmHg. Transfusion of 3 fresh frozen plasma, 1 platelet concentrate, and 3 red blood cells units was started because of acute severe anemia (Hb of 5.4 g/dl) and persistent bleeding from the lungs. The patient also received an injection of 1 mg/kg methylprednisolone. Diffuse alveolar hemorrhage and severe hypoxemia were refractory (PaO2/FiO2 = 40) despite use of neuromuscular blocking agents, inhaled NO, prone positioning, and endotracheal administration of epinephrin. Then a single bolus of 105 lg/kg rVIIa was administrated intravenously. Immediately after the treatment (4 min), bleeding stopped, without any recurrence. No other administration of rVIIa was needed. Inhaled NO was stopped after 48 h, and FiO2 gradually decreased. Extubation was possible after 17 days. No neoplastic or autoimmune diseases were found during the etiological investigations. However, serology returned highly positive for Leptospira icterohaemorrhagiae. The patient left the intensive care unit (ICU) after 3 weeks. Biological data and chest X-ray were normalized. After 4 months, the patient returned to normal activity.