Azithromycin (AZM) is widely used for the treatment of respiratory infection. Macrolides are generally well tolerated and adverse reactions are extremely rare. A 78-year-old man was treated with AZM for upper respiratory infection in November 2007. He developed bloody sputum at 5 days after AZM administration. Chest X-ray and CT images revealed diffuse ground glass opacities in the bilateral lung fields. Bronchoalveolar lavage demonstrated bloody fluid. The clinical symptoms and CT image improved after the corticosteroid therapy. His past history revealed that he also developed similar clinical symptoms and radiological features after treatment with AZM for upper respiratory infection at another hospital in October 2006. At that time, his condition improved after the administration of corticosteroid under a diagnosis of interstitial lung disease of unknown etiology. Finally, we diagnosed recurrent alveolar hemorrhage caused by re-administration of AZM. This is apparently the first reported case of AZM-induced diffuse alveolar hemorrhage.