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Mazarakis A, Bardousis K, Almpanis G, Mazaraki I, Ouzounis A, Kounis NG. Anaphylactic cardiovascular collapse during hemodialysis: Kounis syndrome in the dialysis room. World J Cardiol 2014; 6:1131-1134. [PMID: 25349659 PMCID: PMC4209441 DOI: 10.4330/wjc.v6.i10.1131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 07/12/2014] [Accepted: 08/31/2014] [Indexed: 02/06/2023] Open
Abstract
Kounis syndrome seems to be not a rare disease but a rarely diagnosed disorder. Multiple causes can join forces and trigger the development of this syndrome. We report the first case of Kounis syndrome manifesting as myocardial infarction with cardiovascular collapse that occurred in the dialysis room following an allergic reaction. The dialysis apparatus material of polyurethane, polyamide, polycarbonate, silicon rubber and polypropylene were incriminated causes. Physicians should be aware of the causality and existence of this disorder in order to achieve early and correct diagnosis and apply the appropriate therapeutic measures.
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103
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Kounis NG, Mazarakis A, Almpanis G, Gkouias K, Kounis GN, Tsigkas G. The more allergens an atopic patient is exposed to, the easier and quicker anaphylactic shock and Kounis syndrome appear: Clinical and therapeutic paradoxes. J Nat Sci Biol Med 2014; 5:240-4. [PMID: 25097390 PMCID: PMC4121890 DOI: 10.4103/0976-9668.136145] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Kounis syndrome is a condition that combines allergic, hypersensitivity, anaphylactic or anaphylactoid reactions with acute coronary syndromes including vasospastic angina, acute myocardial infarction and stent thrombosis. This syndrome is a ubiquitous disease affecting patients of any age, involving numerous and continuously increasing causes, with broadening clinical manifestations and covering a wide spectrum of mast cell activation disorders. Drugs, environmental exposures and various conditions are the main offenders. Clinical and therapeutic paradoxes concerning Kounis syndrome therapy, pathophysiology, clinical course and causality have been encountered during its clinical course. Drugs that counteract allergy, such as H2-antihistamines, can induce allergy and Kounis syndrome. The more drugs an atopic patient is exposed to, the easier and quicker anaphylaxis and Kounis syndrome can occur. Every anesthetized patient is under the risk of multiple drugs and substances that can induce anaphylactic reaction and Kounis syndrome. The heart and the coronary arteries seem to be the primary target in severe anaphylaxis manifesting as Kounis syndrome. Commercially available adrenaline saves lives in anaphylaxis but it contains as preservative sodium metabisulfite and should be avoided in the sulfite allergic patients. Thus, careful patient past history and consideration for drug side effects and allergy should be taken into account before use. The decision to prescribe a drug where there is a history of previous adverse reactions requires careful assessment of the risks and potential benefits.
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Affiliation(s)
- N G Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece
| | - A Mazarakis
- Department of Cardiology, "Saint Andrews" State General Hospital, Patras, Achaia, Greece
| | - G Almpanis
- Department of Cardiology, "Saint Andrews" State General Hospital, Patras, Achaia, Greece
| | - K Gkouias
- Department of Cardiology, "Saint Andrews" State General Hospital, Patras, Achaia, Greece
| | - G N Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece
| | - G Tsigkas
- Department of Cardiology, University of Patras Medical School, Patras, Achaia, Greece
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104
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Local and General Anesthetics Immediate Hypersensitivity Reactions. Immunol Allergy Clin North Am 2014; 34:525-46, viii. [DOI: 10.1016/j.iac.2014.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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105
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Thrombus Formation Patterns in HeartMate II Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2014; 60:369-71. [DOI: 10.1097/mat.0000000000000081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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106
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Kounis NG, Soufras GD, Hahalis G. Anaphylactic Shock: Kounis Hypersensitivity-Associated Syndrome Seems to be the Primary Cause. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 5:631-6. [PMID: 24404540 PMCID: PMC3877435 DOI: 10.4103/1947-2714.122304] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Experiments have shown that anaphylaxis decreases cardiac output; increases left ventricular end diastolic pressure; induces severe early acute increase in respiratory resistance with pulmonary interstitial edema; and decreases splanchnic, cerebral, and myocardial blood flow more than what would be expected from severe arterial dilation and hypotension. This is attributed to the constrictive action of inflammatory mediators released during anaphylactic shock. Inflammatory mediators such as histamine, neutral proteases, arachidonic acid products, platelet-activating factor (PAF), and a variety of cytokines and chemokines constitute the pathophysiologic basis of Kounis hypersensitivity-associated acute coronary syndrome. Although the mechanisms of anaphylactic shock still remain to be elucidated, myocardial involvement due to vasospasm-induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered. Searching current experimental and clinical literature on anaphylactic shock pathophysiology, causality, clinical appearance, and treatment via PubMed showed that differentiating global hypoperfusion from primary tissue suppression due to mast cell mediator constrictive action on systemic arterial vasculature is a challenging procedure. Combined tissue suppression from arterial involvement and peripheral vasodilatation, perhaps, occur simultaneously. In cases of anaphylactic shock treatment targeting the primary cause of anaphylaxis together with protection of coronary vasculature and subsequently the cardiac tissue seems to be of paramount importance.
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Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Greece
| | - George D Soufras
- Department of Cardiology, 'Saint Andrews' State General Hospital, Patras, Greece
| | - George Hahalis
- Department of Cardiology, University of Patras Medical School, Rio, Patras, Greece
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107
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Glucagon effects on 3H-histamine uptake by the isolated guinea-pig heart during anaphylaxis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:782709. [PMID: 24895609 PMCID: PMC4034503 DOI: 10.1155/2014/782709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/03/2014] [Accepted: 03/03/2014] [Indexed: 12/16/2022]
Abstract
We estimated the influence of acute glucagon applications on 3H-histamine uptake by the isolated guinea-pig heart, during a single 3H-histamine passage through the coronary circulation, before and during anaphylaxis, and the influence of glucagon on level of histamine, NO, O2−, and H2O2 in the venous effluent during anaphylaxis. Before anaphylaxis, glucagon pretreatment does not change 3H-histamine Umax and the level of endogenous histamine. At the same time, in the presence of glucagon, 3H-histamine Unet is increased and backflux is decreased when compared to the corresponding values in the absence of glucagon. During anaphylaxis, in the presence of glucagon, the values of 3H-histamine Umax and Unet are significantly higher and backflux is significantly lower in the presence of glucagon when compared to the corresponding values in the absence of glucagon. The level of endogenous histamine during anaphylaxis in the presence of glucagon (6.9–7.38 × 10−8
μM) is significantly lower than the histamine level in the absence of glucagon (10.35–10.45 × 10−8
μM). Glucagon pretreatment leads to a significant increase in NO release (5.69 nmol/mL) in comparison with the period before glucagon administration (2.49 nmol/mL). Then, in the presence of glucagon, O2− level fails to increase during anaphylaxis. Also, our results show no significant differences in H2O2 levels before, during, and after anaphylaxis in the presence of glucagon, but these values are significantly lower than the corresponding values in the absence of glucagon. In conclusion, our results show that glucagon increases NO release and prevents the increased release of free radicals during anaphylaxis, and decreases histamine level in the venous effluent during cardiac anaphylaxis, which may be a consequence of decreased histamine release and/or intensified histamine capturing by the heart during anaphylaxis.
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108
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Kounis NG, Soufras GD, Tsigkas G, Hahalis G. White blood cell counts, leukocyte ratios, and eosinophils as inflammatory markers in patients with coronary artery disease. Clin Appl Thromb Hemost 2014; 21:139-43. [PMID: 24770327 DOI: 10.1177/1076029614531449] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Inflammation is a key feature of atherosclerosis and its clinical manifestations. The leukocyte count has emerged as a marker of inflammation that is widely available in clinical practice. Since inflammation plays a key role in atherosclerosis and its end results, discovering new biomarkers of inflammation becomes important in order to help diagnostic accuracy and provide prognostic information about coronary cardiac disease. In acute coronary syndromes and percutaneous coronary intervention, elevated levels of almost all subtypes of white blood cell counts, including eosinophils, monocytes, neutrophils, and lymphocytes, and neutrophil-lymphocyte ratio and eosinophil-leukocyte ratio constitute independent predictors of adverse outcomes. Eosinophil count and eosinophil-leukocyte ratio, in particular, emerge as novel biomarkers for risk stratification in patients with coronary artery disease. Since the presence of eosinophils denotes hypersensitivity inflammation and hypersensitivity associated with Kounis syndrome, this reality is essential for elucidating the etiology of inflammation in order to consider predictive and preventive measures and to apply the appropriate therapeutic methods.
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Affiliation(s)
- Nicholas G Kounis
- Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Greece
| | - George D Soufras
- Departments of Cardiology, University of Patras Medical School, Patras, Greece
| | - Grigorios Tsigkas
- Departments of Cardiology, University of Patras Medical School, Patras, Greece
| | - George Hahalis
- Departments of Cardiology, University of Patras Medical School, Patras, Greece
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109
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Alevizos M, Karagkouni A, Panagiotidou S, Vasiadi M, Theoharides TC. Stress triggers coronary mast cells leading to cardiac events. Ann Allergy Asthma Immunol 2014; 112:309-16. [PMID: 24428962 PMCID: PMC4288814 DOI: 10.1016/j.anai.2013.09.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/30/2013] [Accepted: 09/17/2013] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Stress precipitates and worsens not only asthma and atopic dermatitis but also acute coronary syndromes (ACSs), which are associated with coronary inflammation. Evidence linking stress to ACS was reviewed and indicated that activation of coronary mast cells (MCs) by stress, through corticotropin-releasing hormone (CRH) and other neuropeptides, contributes to coronary inflammation and coronary artery disease. DATA SOURCES PubMed was searched (2005-2013) for articles using the following keywords: allergies, anaphylaxis, anxiety, coronary arteries, coronary artery disease, C-reactive protein, cytokines, chymase, histamine, hypersensitivity, interleukin-6 (IL-6), inflammation, mast cells, myocardial ischemia, niacin, platelet-activating factor, rupture, spasm, statins, stress, treatment, tryptase, and uroctortin. STUDY SELECTIONS Articles were selected based on their relevance to how stress affects ACS and how it activates coronary MCs, leading to coronary hypersensitivity, inflammation, and coronary artery disease. RESULTS Stress can precipitate allergies and ACS. Stress stimulates MCs through the activation of high-affinity surface receptors for CRH, leading to a CRH-dependent increase in serum IL-6. Moreover, neurotensin secreted with CRH from peripheral nerves augments the effect of CRH and stimulates cardiac MCs to release IL-6, which is elevated in ACS and is an independent risk factor for myocardial ischemia. MCs also secrete CRH and uroctortin, which induces IL-6 release from cardiomyocytes. The presence of atherosclerosis increases the risk of cardiac MC activation owing to the stimulatory effect of lipoproteins and adipocytokines. Conditions such as Kounis syndrome, mastocytosis, and myalgic encephalopathy/chronic fatigue syndrome are particularly prone to coronary hypersensitivity reactions. CONCLUSION Inhibition of cardiac MCs may be a novel treatment approach.
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Affiliation(s)
- Michail Alevizos
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts; Present address: Department of Internal Medicine, Jacoby Medical Center, New York, New York
| | - Anna Karagkouni
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts; Present address: Department of Psychiatry, Westchester Hospital, Mt Kisco, New York
| | - Smaro Panagiotidou
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Magdalini Vasiadi
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Theoharis C Theoharides
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts; Department of Internal Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts; Department of Biochemistry, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts; Department of Psychiatry, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts.
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110
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Lerner M, Pal R, Borici-Mazi R. Kounis syndrome and systemic mastocytosis: one step from elective lipoma resection to cardiac arrest. Allergy Asthma Clin Immunol 2014. [PMCID: PMC4126022 DOI: 10.1186/1710-1492-10-s1-a22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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111
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Kounis NG, Soufras GD, Hahalis G. Stent hypersensitivity and infection in sinus cavities. ALLERGY & RHINOLOGY 2014; 4:e162-5. [PMID: 24498522 PMCID: PMC3911806 DOI: 10.2500/ar.2013.4.0071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Persistent mucosal inflammation, granulation tissue formation, hypersensitivity, and multifactorial infection are newly described complications of retained drug-eluting stents from endoscopic sinus surgery for refractory rhinosinusitis. In an important report published in Allergy and Rhinology, a 45-year-old male patient suffering from recalcitrant chronic rhinosinusitis underwent functional endoscopic sinus surgery and was found, for the first time, to have steroid-eluting catheters that were inadvertently left in the ethmoid and frontal sinuses. The retained catheters had caused persistent mucosal inflammation and formation of granulation tissue denoting hypersensitivity reaction. These consequences had induced perpetuation of symptoms of chronic rhinosinusitis. Meticulous removal of the retained stents with the nitinol wings from inflamed tissues of the frontal, ethmoidal, and sphenoethmoidal recesses in which they were completely imbedded was successfully performed without polypoid regrowth. Cultures of specimens taken from both left and right stents showed heavy growth of Stenotrophomonas maltophilia and moderate growth of Klebsiella oxytoca, coagulase negative Staphylococcus, and beta-hemolytic Streptococcus anginosus. Fungal infection was not detected. The current knowledge and experience regarding stent hypersensitivity and infection in relation with the use of stents in sinus cavities is reviewed.
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Affiliation(s)
- Nicholas G Kounis
- of Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece
| | - George D Soufras
- of Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece
| | - George Hahalis
- of Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece
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112
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Kounis NG, Kounis GN, Kouni SN, Soufras GD. Allergy to Heparins, Thrombosis, Thrombocytopaenia and Kounis Syndrome: A Clinical Paradox. Heart Lung Circ 2014; 23:103-4. [DOI: 10.1016/j.hlc.2013.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 06/10/2013] [Accepted: 11/01/2013] [Indexed: 10/26/2022]
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113
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Kounis NG, Soufras GD, Tsigkas G, Hahalis G. White blood count and infarct size, myocardial salvage and clinical outcomes: the role of differentials. Int J Cardiovasc Imaging 2014; 30:677-9. [PMID: 24384860 DOI: 10.1007/s10554-013-0359-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 12/30/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Nicholas G Kounis
- Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece,
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114
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Michaud K, Grabherr S, Shiferaw K, Doenz F, Augsburger M, Mangin P. Acute coronary syndrome after levamisole-adultered cocaine abuse. J Forensic Leg Med 2014; 21:48-52. [DOI: 10.1016/j.jflm.2013.10.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 09/28/2013] [Accepted: 10/27/2013] [Indexed: 12/17/2022]
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115
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Kounis NG, Soufras GD. Coronary stent thrombosis: beware of an allergic reaction and of Kounis syndrome. Indian Heart J 2013; 66:153-5. [PMID: 24814107 DOI: 10.1016/j.ihj.2013.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/04/2013] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece.
| | - George D Soufras
- Department of Cardiology, "Saint Andrews" State General Hospital, Patras, Achaia, Greece
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116
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Kounis NG. Kounis syndrome: a monster for the atopic patient. Cardiovasc Diagn Ther 2013; 3:1-4. [PMID: 24282739 DOI: 10.3978/j.issn.2223-3652.2013.02.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/20/2013] [Indexed: 01/12/2023]
Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Queen Olgas Square, Patras 2622, Greece
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117
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Potaczek DP. Links between allergy and cardiovascular or hemostatic system. Int J Cardiol 2013; 170:278-85. [PMID: 24315352 DOI: 10.1016/j.ijcard.2013.11.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 11/03/2013] [Accepted: 11/17/2013] [Indexed: 12/28/2022]
Abstract
In addition to a well-known immunologic background of atherosclerosis and influences of inflammation on arterial and venous thrombosis, there is growing evidence for the presence of links between allergy and vascular or thrombotic disorders. In this interpretative review, five pretty well-documented areas of such overlap are described and discussed, including: (1) links between atherosclerosis and immunoglobulin E or atopy, (2) mutual effects of blood lipids and allergy, (3) influence of atopy and related disorders on venous thromboembolism, (4) the role of platelets in allergic diseases, and (5) the functions of protein C system in atopic disorders.
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Affiliation(s)
- Daniel P Potaczek
- Institute of Laboratory Medicine, Philipps-Universität Marburg, Marburg, Germany; John Paul II Hospital, Krakow, Poland.
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118
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Anaphylactic shock decreases cerebral blood flow more than what would be expected from severe arterial hypotension. Shock 2013; 39:462-3. [PMID: 23591563 DOI: 10.1097/shk.0b013e3182917393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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119
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Kounis NG, Soufras GD, Hahalis G. Accumulation of eosinophils, mast cells, and basophils in the spleen and the coronary arteries in anaphylactic deaths: is the Kounis hypersensitivity associated syndrome present? Forensic Sci Med Pathol 2013; 10:150-1. [DOI: 10.1007/s12024-013-9489-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 11/29/2022]
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120
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Soufras GD, Kounis GN, Kounis NG. Brain injury due to anaphylactic shock: broadening manifestations of Kounis syndrome. Int Endod J 2013; 47:309-13. [PMID: 23889503 DOI: 10.1111/iej.12152] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 06/13/2013] [Indexed: 11/26/2022]
Abstract
Anaphylactic shock is a real and life threatening medical emergency which is encountered in every field of medicine. The coronary arteries seem to be the primary target of anaphylaxis resulting in the development of Kounis syndrome. Kounis syndrome is a pan-arterial anaphylaxis -associated syndrome affecting patients of any age, involving numerous and continuously increasing causes, with broadening clinical manifestations and covering a wide spectrum of mast cell activation disorders. Recently, Kounis-like syndrome affecting the cerebral arteries was found to be associated with mast cell activation disorders. In anaphylactic shock, the decrease of cerebral blood flow is more than what would be expected from severe arterial hypotension. This is attributed to the early and direct action of anaphylactic mediators on cerebral vessels. While adrenaline is a life saving agent in the treatment of anaphylactic shock, it contains sodium betabisulfite as preservative and should be avoided in sulfite allergic patients. Potential allergens encountered in endodotic practice include formocresol, zinc compounds thiurams, sodium dimethyldithiocarbamade, and mercaptobenzothiazole that might have synergistic action. All these agents together with analgesics, antibiotics, antiseptics, formaldehyde, latex, local anaesthetics and metals used in dental practice, in general, can induce anaphylactic shock. Practitioners should be aware of these consequences. A careful history of previous atopy and reactions is of paramount importance for safe and effective management.
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Affiliation(s)
- G D Soufras
- Department of Cardiology, 'Saint Andrews' State General Hospital, Patras, Greece
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121
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Suicidal anaphylactic death: is Kounis anaphylaxis associated syndrome the cause? Forensic Sci Int 2013; 232:e42-3. [PMID: 23891484 DOI: 10.1016/j.forsciint.2013.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 01/09/2023]
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122
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Non-ST segment elevation myocardial infarction after multiple bee stings. A case of “delayed” Kounis II syndrome? Int J Cardiol 2013; 166:e62-5. [DOI: 10.1016/j.ijcard.2013.01.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022]
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123
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Kounis NG. Caspofungin-induced fatal complete heart block: Another manifestation of Kounis syndrome. J Pharmacol Pharmacother 2013; 4:161-2. [PMID: 23761719 PMCID: PMC3669582 DOI: 10.4103/0976-500x.110918] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Greece
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124
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Kounis NG, Soufras GD. Nerve, muscle and heart acute toxicity following oxaliplatin and capecitabine treatment. Neuromuscul Disord 2013; 23:524-5. [DOI: 10.1016/j.nmd.2013.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 03/20/2013] [Indexed: 10/26/2022]
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125
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Kajihara H. Letter to Dr. Kounis. Virchows Arch 2013; 462:689-90. [DOI: 10.1007/s00428-013-1420-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 04/26/2013] [Indexed: 11/30/2022]
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126
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Soufras GD, Kounis NG. Adrenaline administration for anaphylaxis and the risk of takotsubo and Kounis syndrome. Int J Cardiol 2013; 166:281-2. [DOI: 10.1016/j.ijcard.2012.12.075] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 11/11/2012] [Accepted: 12/25/2012] [Indexed: 10/27/2022]
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127
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Kounis NG, Soufras GD, Almpanis G, Tsigkas G, Mazarakis A. Acute stent thrombosis and heparin induced thrombocytopenia: another manifestation of kounis syndrome? Korean Circ J 2013; 43:221-2. [PMID: 23682280 PMCID: PMC3654108 DOI: 10.4070/kcj.2013.43.4.221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences Patras Highest Institute of Education and Technology, Patras, Greece and Department of Cardiology, Saint Andrews State General Hospital, Patras, Greece
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128
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Mukta V, Chandragiri S, Das AK. Allergic myocardial infarction. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:157-8. [PMID: 23641382 PMCID: PMC3624721 DOI: 10.4103/1947-2714.107544] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- V Mukta
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. E-mail:
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Kounis NG, Mazarakis A, Tsigkas G. Eosinophilic coronary periarteritis presenting with vasospastic angina and sudden death: a new cause and manifestation of Kounis syndrome? Virchows Arch 2013; 462:687-8. [DOI: 10.1007/s00428-013-1406-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 03/25/2013] [Indexed: 10/27/2022]
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Kounis N, Kounis G. Anaphylactic cardiovascular collapse during anesthesia: the Kounis acute hypersensitivity syndrome seems to be the most likely cause. J Korean Med Sci 2013; 28:638-9. [PMID: 23580866 PMCID: PMC3617323 DOI: 10.3346/jkms.2013.28.4.638] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Nicholas Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Greece
| | - George Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Greece
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Kounis NG. Coronary hypersensitivity disorder: the Kounis syndrome. Clin Ther 2013; 35:563-71. [PMID: 23490289 DOI: 10.1016/j.clinthera.2013.02.022] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 02/21/2013] [Accepted: 02/25/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND When allergy or hypersensitivity and anaphylactic or anaphylactoid insults lead to cardiovascular symptoms and signs, including acute coronary events, the result might be the recently defined nosologic entity Kounis syndrome. Vasospastic allergic angina, allergic myocardial infarction, and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells are the 3 reported variants of this syndrome. OBJECTIVE The purpose of this review was to highlight and consolidate the recent literature on allergic angina and allergic myocardial infarction and to propose new therapeutic modalities for stabilizing mast cells. METHODS A search for current literature on the pathophysiology, causality, clinical appearance, variance, prevention, and treatment of Kounis syndrome was conducted. RESULTS Kounis syndrome is caused by inflammatory mediators such as histamine; neutral proteases, including tryptase, chymase, and cathepsin-D; arachidonic acid products; platelet-activating factor; and a variety of cytokines and chemokines released during the mast-cell activation. Platelets with Fc γ receptor (FcγR) Ι, FcγRII, FcεRI, and FcεRII also have a role in the activation cascade. The same mediators released from the similar inflammatory cells are involved in acute coronary events of nonallergic etiology. These cells are not only present in the involved region before plaque erosion or rupture but also release their contents just before an acute coronary event. Pro-inflammatory mediators similar to those found in Kounis syndrome are found in some cases with nonallergic etiology, suggesting that this is a more general problem. The acute coronary and cerebrovascular events in Kounis syndrome may be prevented by the inhibition of mast-cell degranulation. Substances and natural molecules that protect the mast-cell surface and stabilize the mast-cell membrane are emerging as novel agents in the prevention of acute coronary and other arterial events. CONCLUSIONS The 3 reported variants of Kounis syndrome-vasospastic allergic angina, allergic myocardial infarction, and stent thrombosis with occluding thrombus-are caused by inflammatory mediators. Agents that inhibit mast-cell degranulation may be efficacious in preventing the acute coronary and cerebrovascular events of Kounis syndrome.
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Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Greece.
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Abstract
Mast cells are increasingly being recognized as effector cells in many cardiovascular conditions. Many mast-cell-derived products such as tryptase and chymase can, through their enzymic action, have detrimental effects on blood vessel structure while mast cell-derived mediators such as cytokines and chemokines can perpetuate vascular inflammation. Mice lacking mast cells have been developed and these are providing an insight into how mast cells are involved in cardiovascular diseases and, as knowledge increase, mast cells may become a viable therapeutic target to slow progression of cardiovascular disease.
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Kounis hypersensitivity coronary syndrome is associated with presence of older thrombus in patients with late and very late drug-eluting stent thrombosis. J Cardiol 2012; 60:338. [DOI: 10.1016/j.jjcc.2012.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 05/04/2012] [Indexed: 11/24/2022]
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Kounis NG, Davlouros P, Hahalis G, Mazarakis A. The heart seems to be the primary site and the target of anaphylaxis resulting in the development of Kounis syndrome. Intern Emerg Med 2012; 7 Suppl 2:S119-20. [PMID: 22527679 DOI: 10.1007/s11739-012-0786-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/06/2012] [Indexed: 10/28/2022]
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Kounis NG, Hahalis G, Davlouros P, Mazarakis A. Commentary on:Feltracco P, Barbieri S, Galligioni H, Pasin L, Gaudio RM, Tommasi A, et al. A fatal case of anaphylactic shock during paragliding. J Forensic Sci 2012; doi: 10.1111/j.1556-4029.2012.02187.x [Epub ahead of print]. J Forensic Sci 2012; 57:1400-1; author reply 1402. [DOI: 10.1111/j.1556-4029.2012.02233.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Nicholas G. Kounis
- Department of Medical Sciences; Patras Highest Institute of Education and Technology; Patras 26221 Greece
| | - George Hahalis
- Department of Cardiology; University of Patras Medical School; Rion Patras 26500 Greece
| | - Periklis Davlouros
- Department of Cardiology; University of Patras Medical School; Rion Patras 26500 Greece
| | - Andreas Mazarakis
- Department of Cardiology; University of Patras Medical School; Rion Patras 26500 Greece
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Feltracco P, Gaudio RM, Avato FM, Ori C. Authors' Response. J Forensic Sci 2012. [DOI: 10.1111/j.1556-4029.2012.02232.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Paolo Feltracco
- Department of Anesthesiology and Intensive Care; University of Padova; Via Cesare Battisti 267 35100 Padova Italy
| | - Rosa Maria Gaudio
- Department of Legal Medicine; University of Ferrara; Via Fossato di Mortara 66 44121 Ferrara Italy
| | - Francesco Maria Avato
- Department of Legal Medicine; University of Ferrara; Via Fossato di Mortara 66 44121 Ferrara Italy
| | - Carlo Ori
- Department of Anesthesiology and Intensive Care; University of Padova; Via Cesare Battisti 267 35100 Padova Italy
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Kounis syndrome due to angiotensin converting enzyme inhibitor. Clin Res Cardiol 2012; 102:163-4. [DOI: 10.1007/s00392-012-0504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 07/31/2012] [Indexed: 11/27/2022]
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Late left Atrial Thrombosis of an Amplatzer patent foramen ovale occluder may be the result of Kounis hypersensitivity-associated syndrome. J Thorac Cardiovasc Surg 2012; 144:276; author reply 276-7. [DOI: 10.1016/j.jtcvs.2012.03.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 03/12/2012] [Indexed: 11/21/2022]
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González-de-Olano D, Matito A, Sánchez-López P, Sánchez-Muñoz L, Morgado JM, Teodósio C, Jara-Acevedo M, García-Montero A, Orfao A, Escribano L, Kounis NG, Álvarez-Twose I. Mast cell-related disorders presenting with Kounis syndrome. Int J Cardiol 2012; 161:56-8. [PMID: 22748285 DOI: 10.1016/j.ijcard.2012.06.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 06/09/2012] [Indexed: 11/19/2022]
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Mazarakis A, Tsigkas G, Soufras GD, Kounis NG. Anti chimeric antibodies against chimeric monoclonal antibodies may result in Kounis hypersensitivity associated acute coronary syndrome. J Crohns Colitis 2012; 6:632-3. [PMID: 22398073 DOI: 10.1016/j.crohns.2012.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 01/22/2012] [Indexed: 02/08/2023]
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Mazarakis A, Karogiannis NC, Almpanis GC, Servos G, Dimopoulos DA, Tsigkas G, Kounis NG. Subclinical and clinical presentation of Kounis syndrome: Another cause of troponin elevation? Int J Cardiol 2012; 157:258-60. [DOI: 10.1016/j.ijcard.2012.03.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 03/03/2012] [Indexed: 10/28/2022]
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