Pulmonary Alveolar Hemorrhage after Clopidogrel Use for ST Elevation Myocardial Infarction
A 62-year-old man was transferred to our hospital because of chest pain. The patient had a medical history of hypertension and had been a heavy smoker for 40 pack-years. On arrival, his blood pressure was 114/70 mm Hg, heart rate was 75 bpm, respiratory rate was 16/minute, and body temperature was 36.5℃. White blood cell count was 13930/mm3, hemoglobin was 14.2 g/dL, and platelets were 294000/mm3. Aspartate aminotransferase was 79 U/L and alanine aminotransferase was 104 U/L. Blood urea nitrogen, creatinine, and electrolytes were all within normal limits. Electrocardiogram showed an ST elevation in the V 1 through V 6 leads, and ST depression in the II, III and aVF leads. The patient was diagnosed as having ST elevation myocardial infarction. After the patient had taken 300 mg aspirin and 600 mg clopidogrel, he underwent primary PCI. Coronary angiograms showed 99% stenosis of the mid-left anterior descending artery (). Therefore, a coronary stent (Endeavor®, Zotarolimus-Eluting Coronary Stent, 3.0×26 mm, Medtronic) was implanted (). The patient was admitted to the coronary care unit (CCU) and triple antiplatelet therapy was started.\nOn the third day after admission, the patient coughed up bloody sputum and had a fever. The chest radiograph showed mild infiltration of both upper lung fields (). We diagnosed pneumonia and administered piperacillin/tazobactam. The patient's vital signs, symptoms, and cardiac markers improved; then the patient was transferred to the general ward.\nOn the sixth day after admission, the patient complained of dyspnea and continuous bloody sputum. Chest computed tomography with enhancement showed patchy areas of ground-glass opacity in a central distribution in both upper lobes (). The findings were consistent with diffuse alveolar hemorrhage. We considered triple antiplatelet therapy as the most likely cause. We discontinued cilostazol and carried out a study to discriminate between alveolar hemorrhage caused by antiplatelet therapy and alveolar hemorrhage due to a different disease. Anti-phospholipid antibody, anti-cardiolipin antibody, P-antinuclear and antineutrophil cytoplasmic autoantibodies (ANCA), C-ANCA, ANA, complement 3, complement 4, anti-ds deoxyribonucleic acid antibody, anti-Leptospira antibody were all negative. The patient's platelet count was 257000/mm3.\nOn the eleventh day after admission, the patient suddenly fell into acute respiratory failure and was transferred to the CCU. We intubated the patient. The chest radiograph showed diffuse infiltration in both lung fields (). Bronchoscopy revealed diffuse hemorrhage of the bronchial walls in the bilateral lung fields. We discontinued clopidogrel on the ninth day after admission.\nOn the seventeenth day after admission, his symptoms improved and we extubated the patient. The chest radiograph showed decreased infiltration of both the lung fields (). The patient was transferred to the general ward. The patient wanted to be transferred to another hospital. On the third day after the transfer, the patient died of ventricular fibrillation at the hospital to which he had been transferred.