Massive pulmonary bleeding due to invasive aspergillosis is often a fatal complication in patients with acute leukemia.1 We describe successful treatment with recombinant factor VIIa (rFVIIa) (Novoseven; Novo Nordisk, Copenhagen, Denmark) in a patient with this condition.
A 49-year-old man developed unexplained fever while he was severely neutropenic (0.003 × 109/L) after induction chemotherapy for acute lymphoblastic leukemia (Figure 1). The fever did not respond to antibiotic treatment. Because chest radiograph findings then showed a small pulmonary infiltrate in the left lower lobe, bronchoalveolar lavage was performed. An infectious agent could not be demonstrated. Approximately 10 days later, he began to cough up a little blood. His platelet count was 8 × 109/L; prothrombin time was normal. The infiltrate seen on chest radiographs had extended, and a perihilar infiltrate had developed on the right side. Mild hemoptysis persisted despite multiple transfusions of platelet concentrates and administration of tranexamic acid. Two days later, he experienced massive pulmonary bleeding. A single dose of 90 µg/kg of rFVIIa was given by intravenous injection, preceded and followed by transfusions of platelet concentrates. The bleeding promptly stopped. Two units of red blood cell concentrates were needed to keep hemoglobin concentration at 5 mmol/L, and antifungal therapy was started. Administration of rFVIIa was not repeated because of the high probability of bad outcome of a cerebral hemorrhage. After 4 days, at platelet counts that remained lower than 10 × 109/L despite transfusions of platelet concentrates, the patient became progressively more somnolent and died within a few hours, probably due to cerebral bleeding. Permission for autopsy to confirm the diagnosis of aspergillosis was not obtained.