Kounis syndrome: A concise review with focus on management

Kounis and Takotsubo, Two Syndromes Bound by Adrenaline: The "ATAK" Complex

Background. The term "ATAK" complex has been coined by the association of adrenaline, takotsubo, anaphylaxis and Kounis syndrome. We present an uncommon case of an "ATAK" complex with biphasic onset and a midventricular takotsubo pattern. Case Summary. A 50-year-old male was brought to the emergency department in anaphylactic shock. He had progressive exertional dyspnea and angina for the past 2 days. The intravenous administration of adrenaline for anaphylactic shock resulted in chest pain and concerning ECG repolarization findings. The patient was immediately transferred to the catheterization laboratory. Coronary angiography showed a midventricular ballooning pattern without significant coronary stenosis, with subsequent recovery during hospitalization, suggestive of takotsubo syndrome. The allergy tests remained inconclusive for the trigger. Discussion. Adrenaline-mediated stress is the link between these two entities, in which Kounis syndrome itself or anaphylactic shock treatment (adrenaline) are potential triggers for takotsubo syndrome.

A Rare Case of Kounis Syndrome Secondary to Infliximab

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or anaphylactic reactions. It manifests as coronary artery vasospasm, acute myocardial infarction, or coronary stent thrombosis, resulting from inflammatory cytokine release and inappropriate activation of platelets and mast cells. We present a case of an 85-year-old male with Crohn's disease who suffered anaphylaxis during infliximab infusion, culminating in non-ST myocardial infarction (NSTEMI). The patient's symptoms were effectively managed with epinephrine and diphenhydramine, and KS secondary to infliximab was diagnosed. Diagnosing KS can be challenging due to the overlapping signs of an allergic reaction and myocardial infarction. Timely recognition and appropriate management of KS are crucial to enhance patient outcomes. Therefore, healthcare providers should maintain a high index of suspicion for KS in patients with acute coronary syndromes linked to allergic reactions to optimize care and minimize potential risks. This case report underscores the significance of prompt intervention and awareness of Kounis syndrome in clinical practice.

Allergic Acute Coronary Syndrome-Kounis Syndrome

Acute coronary syndrome (ACS) in the setting of an allergic/immunologic reaction is known as Kounis syndrome. It is an underdiagnosed and underrecognized disease entity. One must keep a high index of suspicions when managing a patient presenting with cardiac as well as allergic symptoms. There are 3 main variants to the syndrome. Treating the allergic reaction may alleviate the pain; however, ACS guidelines should be followed if cardiac ischemia is present.

Kounis syndrome in a patient following AstraZeneca coronavirus disease 2019 vaccination: a case report

INTRODUCTION AND IMPORTANCE

Kounis syndrome, also known as allergic angina syndrome, is defined as the occurrence of an acute coronary syndrome concomitantly with a hypersensitivity reaction. It is a very important diagnosis and missing it may be fatal to the patient. This is a medical emergency, and immediate treatment should be initiated. The treatment of Kounis syndrome is challenging because treatment of either acute coronary syndrome and hypersensitivity reaction can lead to the worsening of the other injury. This case is the first reported case of Kounis syndrome following coronavirus disease 2019 vaccination in Sri Lanka according to our knowledge.

CASE PRESENTATION

We discuss a 54-year-old female Sri Lankan patient who developed Kounis syndrome following Oxford AstraZeneca COVID-19 vaccination. The patient initially developed anaphylaxis following the AstraZeneca COVID-19 vaccine and subsequently developed acute coronary syndrome secondary to anaphylaxis. The patient was treated appropriately and eventually recovered from her condition.

CONCLUSION

This syndrome should be suspected when there is a concurrent acute coronary syndrome with allergic reactions. This is an often under- or misdiagnosed condition, and physicians should be educated about it. Caregivers should be aware of its pathophysiology, as treatment of either of the two may worsen the other injury.

Drug-Induced Kounis Syndrome: Latest Novelties

Kounis syndrome (KS) is defined by an acute coronary syndrome associated with hypersensitivity reactions, an under-diagnosed life-threatening medical emergency. Although multiple causes have been described, drugs constitute the most frequent cause. The purpose of this review is to update knowledge about drug-induced KS, to give guidelines on the correct diagnosis and treatment. This article reviews the literature on drug-induced KS from the last 5 years. Antibiotics and NSAIDs are the most frequently implicated drugs. In addition, data on pathophysiology, clinical presentation, diagnosis, and management are reviewed in detail. Highlight that there is a great deal of variability in the diagnosis and especially in the treatment of KS. This review provides a valuable selection of practical resources for all stakeholders to support effective care for KS, from a cardiologic and allergologic point of view. Future research should focus on developing validated, evidence-based, and patient-centered tools to improve the management of KS.

The Role of Mast Cells in the Induction and Maintenance of Inflammation in Selected Skin Diseases

Under physiological conditions, skin mast cells play an important role as guardians that quickly react to stimuli that disturb homeostasis. These cells efficiently support, fight infection, and heal the injured tissue. The substances secreted by mast cells allow for communication inside the body, including the immune, nervous, and blood systems. Pathologically non-cancerous mast cells participate in allergic processes but also may promote the development of autoinflammatory or neoplastic disease. In this article, we review the current literature regarding the role of mast cells in autoinflammatory, allergic, neoplastic skin disease, as well as the importance of these cells in systemic diseases with a pronounced course with skin symptoms.

Case report: Ioversol induced Kounis syndrome and cardiogenic shock

A 50-year-old male patient was admitted to the Cardiology Department of our hospital for intermittent chest pain for 9 days. Coronary angiography showed approximately 70% stenosis in the middle part of the left anterior descending branch. When the procedure was about to end, the patient experienced dyspnea, facial flushing and fall of blood pressure suddenly. At this time, the angiography showed severe spasm and stenosis of the left coronary artery. With antianaphylaxis, pressor therapy, fluid resuscitation and intracoronary administration of nitroglycerin, the left coronary spasm was relieved. A diagnosis of type II kounis syndrome induced by ioversol with cardiogenic shock was made.

Kounis syndrome following multiple wasp stings: A case report

This is a case of Kounis syndrome with chest tightness, lightheadedness, unconsciousness, and features of shock following multiple wasp stings. Despite cardiopulmonary resuscitation and management of allergic and cardiac symptoms, the patient died. Kounis syndrome should be suspected when a patient presents with allergic symptoms and acute coronary syndrome.

Case report: Cefoperazone-sulbactam induced Kounis syndrome and cardiogenic shock

Background

Kounis syndrome is a hypersensitive coronary artery disease caused by the body's exposure to allergens, which is induced by various drugs and environmental factors. This entity has been described primarily in isolated case reports and case series. We report a case of type III Kounis syndrome caused by cefoperazone-sulbactam.

Case presentation

A 79-year-old man who received an infusion of cefoperazone-sulbactam in Respiratory Department of our hospital for recurrent infections. 28 minutes later, he developed skin flushing of the trunk and extremities, soon followed by loss of consciousness and shock. With antianaphylaxis, pressor therapy, and fluid rehydration, the patient was admitted to the ICU for treatment. During which, he experienced recurrent ventricular fibrillation and a progressive increase in troponin I levels. The ECG of the patient showed that the ST segment elevation of lead II, III, avF, and V3R–V5R was 0.10–0.20 MV. An urgent coronary angiography showed an in-stent thrombosis in the middle part of the right coronary artery, occlusion of the distal flow with TIMI grade 0. The diagnosis was type III Kounis syndrome with cardiogenic shock. Despite aggressive treatment, the patient died on day 7 after ICU admission.

Conclusion

Kunis syndrome is a life-threatening disease, and therefore allergic reactions in patients with a history of cephalosporin allergy and coronary stent implantation should be considered and treated promptly.

Kounis Syndrome That Recurs in A Short Time Period: A Case Report

This case report is unique for the occurrence of a quickly recurring Kounis Syndrome (KS) due to re-exposure to the same agent. A 40-year-old male was brought to our ED with a diagnosis of non-ST-segment elevation myocardial infarction. He stated that he had taken one dose of amoxicillin-clavulanate 1,000 mg at 03.00 AM. After taking the drug, chest pain and vomiting began. ECG which was taken at the the rural hospital, revealed a normal sinus rhythm with no ischemic changes. The value of cardiac troponin I 0.34 ng/ml in the rural hospital. The patient was consultated to the cardiology clinic with a pre-diagnosis of KS. Percutaneous coronary intervention showed that coronary arteries were normal and no plaque formation was found. The patient, who was diagnosed with type I KS, left the hospital at his own request at 14:12 PM. The patient presented to our ED again at 22:30 PM with chest pain and shortness of breath after accidentally using the same allergenic drug ~eight hours after leaving our hospital. ECG showed > 0.5 cm ST-segment elevation in leads DII, DIII, and aVF. Quickly recurring KS was due to accidental reuse of the same agent may be more severe than the first occurrence.

The impact of type 2 immunity and allergic diseases in atherosclerosis

Allergic diseases are allergen-induced immunological disorders characterized by the development of type 2 immunity and IgE responses. The prevalence of allergic diseases has been on the rise alike cardiovascular disease (CVD), which affects arteries of different organs such as the heart, the kidney and the brain. The underlying cause of CVD is often atherosclerosis, a disease distinguished by endothelial dysfunction, fibrofatty material accumulation in the intima of the artery wall, smooth muscle cell proliferation, and Th1 inflammation. The opposed T-cell identity of allergy and atherosclerosis implies an atheroprotective role for Th2 cells by counteracting Th1 responses. Yet, the clinical association between allergic disease and CVD argues against it. Within, we review different phases of allergic pathology, basic immunological mechanisms of atherosclerosis and the clinical association between allergic diseases (particularly asthma, atopic dermatitis, allergic rhinitis and food allergy) and CVD. Then, we discuss putative atherogenic mechanisms of type 2 immunity and allergic inflammation including acute allergic reactions (IgE, IgG1, mast cells, macrophages and allergic mediators such as vasoactive components, growth factors and those derived from the complement, contact and coagulation systems) and late phase inflammation (Th2 cells, eosinophils, type 2 innate-like lymphoid cells, alarmins, IL-4, IL-5, IL-9, IL-13 and IL-17).

Clinical features, diagnosis and management of amoxicillin-induced Kounis syndrome

Background: The available evidence suggests that amoxicillin is often associated with the occurrence of Kounis syndrome (KS). The purpose of this study is to explore the clinical characteristics of KS induced by amoxicillin.

Methods: We searched for case reports of amoxicillin-induced KS through Chinese and English databases from 1972 to May 2022.

Results: A total of 33 patients with KS were included, including 16 patients (48.5%) receiving amoxicillin treatment and 17 patients (51.5%) receiving amoxicillin-clavulanate. The median age was 58 years (range 13–82), 75.8% were from Europe and 81.8% were male. Nearly 70% of KS patients develop symptoms within 30 min after administration. Chest pain (63.6%) and allergic reaction (75.8%) were the most common clinical manifestations. Diagnostic evaluation revealed elevated troponin (72.7%), ST-segment elevation (81.2%) and coronary artery stenosis with thrombosis (53.6%). Thirty-two (97.0%) patients recovered completely after discontinuation of amoxicillin and treatments such as steroids and antihistamines.

Conclusion: KS is a rare adverse reaction of amoxicillin. Amoxicillin-induced KS should be considered when chest pain accompanied by allergic symptoms, electrocardiogram changes and or elevated levels of myocardial injury markers. Therapeutic management of KS requires simultaneous treatment of cardiac and allergic symptoms. Epinephrine should be used with caution in patients with suspected KS.

Analysis of Clinical Features of Non-steroidal Anti-inflammatory Drugs Induced Kounis Syndrome

Background

Current knowledge of Kounis syndrome induced by non-steroidal anti-inflammatory drugs (NSAIDs) is based on case reports. This study aimed to investigate the clinical features of Kounis syndrome.

Methods

Case reports of the NSAIDs-induced Kounis syndrome were analyzed by searching Chinese and English databases from 1 January 1950 to 31 January 2022.

Results

The median age of the 45 included patients (28 women) was 51 years (20–80 years). NSAIDs that were the most frequently involved were diclofenac (26.7%, 12/45), metamizole (15.6%, 7/45), and aspirin (13.3%, 6/45). Kounis syndrome occurred mainly within 30 min after administration, with a maximum latency of 1 month. Chest pain (75.6%, 34/45), dyspnea (33.3%, 15/45), and allergic reactions (44.4%, 20/45) were the most common clinical manifestations. Thirty patients (66.7%) had an ST-segment elevation on the electrocardiogram. Echocardiogram and coronary angiography showed abnormalities in 21 patients (75%, 21/28) and 15 patients (37.5%, 15/40). Forty-four patients (97.8%) had a good prognosis after treatment with steroids, antihistamines, and vasodilators.

Conclusion

The possibility of Kounis syndrome should be considered in the presence of coronary artery disease symptoms when taking NSAIDs. Kounis syndrome can be life-threatening. It is essential to identify and treat Kounis syndrome correctly.

Early Use of ECMO for Refractory Kounis Syndrome Concealed by General Anesthesia—A Case Report

A 46-year-old woman demonstrated refractory Kounis syndrome (KS) after induction of anesthesia. Despite conventional management of anaphylaxis and advanced cardiac life support, her cardiovascular function continued to deteriorate until she had a cardiac arrest, and after extracorporeal membrane oxygenation (ECMO) therapy, electrical cardiac activity reappeared. A large number of patients with KS—“allergic angina syndrome”—has been known to recover well with vasodilators; however, this patient showed antibiotics-induced refractory KS during general anesthesia. Severe bronchospasms with desaturation appeared as initial anaphylactic features; however, these did not respond to conventional treatment for anaphylaxis. Patient’s hemodynamic signs eventually worsened, leading to cardiac arrest despite ephedrine administration and chest compressions. During cardiopulmonary cerebral resuscitation, the central line was secured, and epinephrine, atropine, as well as sodium bicarbonate were administered repeatedly; nevertheless, cardiac arrest was sustained. After initiation of veno-arterial ECMO, atrial fibrillation was observed, which was later converted to sinus tachycardia by electrical cardioversions and amiodarone. Coronary angiography was performed before the patient was admitted to the intensive care unit; there were no indications of an impending cardiac arrest. The patient was discharged uneventfully owing to early use of ECMO despite the emergence of KS symptoms that were initially masked by anesthesia but later worsened abruptly.

An unusual case of concurrent Kounis syndrome and prolonged QT in a young patient

Allergic reactions related to drug use is a common entity presenting often from minor urticaria to life-threatening anaphylactoid reactions. A common but easily overlooked diagnosis, Kounis syndrome, is an established hypersensitivity coronary disorder induced by drugs, foods, environmental factors, and coronary stents that can present in the same way as non-allergy-induced acute coronary syndrome. Here within, we present a unique case of dual presentation of Kounis syndrome and prolonged QTc in a young patient after a single dose of Domperidone and Lansoprazole.

An unusual case of concurrent Kounis syndrome and prolonged QT in a young patient

Allergic reactions related to drug use is a common entity presenting often from minor urticaria to life-threatening anaphylactoid reactions. A common but easily overlooked diagnosis, Kounis syndrome, is an established hypersensitivity coronary disorder induced by drugs, foods, environmental factors, and coronary stents that can present in the same way as non-allergy-induced acute coronary syndrome. Here within, we present a unique case of dual presentation of Kounis syndrome and prolonged QTc in a young patient after a single dose of Domperidone and Lansoprazole.

Analysis of Clinical Features of Kounis Syndrome Induced by Cephalosporin

Background

Cephalosporins are an increasingly encountered cause of Kounis syndrome. The present study examined the clinical features of cephalosporin-induced Kounis syndrome and provided references for diagnosis, prevention, treatment, and prognosis.

Methods

We collected cephalosporin-induced Kounis syndrome case reports by searching Chinese and English databases from the establishment of the database to October 31, 2021.

Results

Twenty-five patients (17 males and eight females) were included, with a median age of 61 years (range 33–92). Cephalosporins were administered via oral, intravenous and intramuscular routes. All reactions occurred within 30 min, except in two patients. Fourteen patients experienced chest pain, 19 experienced hypotension, 16 had cutaneous reactions, 10 had respiratory symptoms, and seven had gastrointestinal symptoms. Thirteen patients had elevated troponin levels, and eight patients had elevated serum tryptase levels. The electrocardiogram showed ST-segment elevation in 13 patients, depression in four patients, and elevation and depression in six patients. Coronary angiography showed normal results in 12 patients and abnormal results in 13 patients. The skin prick test was positive for cephalosporin in three patients. Twenty-four of the 25 patients recovered after being given anti-allergic and acute coronary syndrome treatment, and there was one death.

Conclusions

Kounis syndrome is a serious adverse reaction to cephalosporin. Clinicians should consider Kounis syndrome in every patient receiving cephalosporin and presenting with acute chest pain or anaphylactic symptoms.

Iodinated contrast media induced Kounis syndrome during coronary angiogram: a life-threatening clinical dilemma

Kounis syndrome (KS) is a well-documented hypersensitivity vasospastic reaction induced by a variety of triggers. Clinical presentation ranges from non-specific symptoms such as dizziness and nausea to myocardial infarction. Many cases of KS were reported after the use of iodinated contrast media, mainly during radiological procedures. This report describes the case of a 46-year-old man developing coronary vasospasm and anaphylactic shock at the end of percutaneous coronary intervention. Occurrence of such pathology while performing coronary angiogram is a tricky situation for the invasive cardiologist. It requires recognising a rare syndrome and interrupting the procedure to avoid extra use of contrast media even in presence of severe coronary lesions due to vasospasm. Every interventionalist should be aware of such a presentation to recognise and react promptly when facing a potentially life-threatening clinical dilemma.

Allergy Associated Myocardial Infarction: A Comprehensive Report of Clinical Presentation, Diagnosis and Management of Kounis Syndrome

Kounis syndrome (KS) has been defined as acute coronary syndrome (ACS) in the context of a hypersensitivity reaction. Patients may present with normal coronary arteries (Type I), established coronary artery disease (Type II) or in-stent thrombosis and restenosis (Type III). We searched PubMed until 1 January 2020 for KS case reports. Patients with age <18 years, non-coronary vascular manifestations or without an established diagnosis were excluded. Information regarding patient demographics, medical history, presentation, allergic reaction trigger, angiography, laboratory values and management were extracted from every report. The data were pulled in a combined dataset. From 288 patients with KS, 57.6% had Type I, 24.7% Type II and 6.6% Type III, while 11.1% could not be classified. The mean age was 54.1 years and 70.6% were male. Most presented with a combination of cardiac and allergic symptoms, with medication being the most common trigger. Electrocardiographically, 75.1% had ST segment elevation with only 3.3% demonstrating no abnormalities. Coronary imaging was available in 84.8% of the patients, showing occlusive lesions (32.5%), vascular spasm (16.2%) or normal coronary arteries (51.3%). Revascularization was pursued in 29.4% of the cases. In conclusion, allergic reactions may be complicated by ACS. KS should be considered in the differential diagnosis of myocardial infarction with non-obstructive coronary arteries.

Recognizing Kounis Syndrome: A Report of Type 2 Kounis Syndrome and a Brief Review of Management

Kounis syndrome is an underdiagnosed medical condition and represents acute coronary syndrome in the setting of allergic reaction. With the increasing prevalence of allergic reactions, more cases of Kounis syndrome are being reported in the literature. Recognizing patients with acute coronary syndrome during an episode of anaphylaxis may be difficult due to symptom overlap; hence, a high index of suspicion must be maintained. This is vital as the management of Kounis syndrome requires meticulous use of medications as some pharmacological agents beneficial to acute coronary syndrome may be detrimental for the ongoing anaphylaxis and vice versa. We report a case of type 2 variant of Kounis syndrome following severe anaphylaxis to nuts to highlight the need for clinicians to suspect Kounis syndrome when managing patients with anaphylaxis and chest symptoms.

Kounis syndrome secondary to nimesulide ingestion: a case report

Background

Kounis syndrome, also known as "allergic myocardial infarction," is a rare co-occurrence of acute coronary syndrome (ACS) in the setting of hypersensitivity reaction to any agent. Non-steroidal anti-inflammatory drugs (NSAIDs) like are often implicated in causing allergic reactions. Here, we present a case of anterior wall myocardial infarction (AWMI) occurred following angioedema secondary to intake of Nimesulide, not described earlier in literature.

Case presentation

A 45-year-old female developed generalized pruritic, erythematous maculopapular rash, facial puffiness, oral ulcers and hoarseness of voice within few hours following consumption of Nimesulide for fever and body-ache. Due to development of hypotension, electrocardiogram (ECG) was done, which revealed ST elevation in V2–V6, with marked elevation of troponin (TnI) and creatine kinase (CK-MB). He had no chest pain or shortness of breath. Echocardiography showed regional wall motion (RWMA) abnormality in left anterior descending artery (LAD) territory with an ejection fraction of 25%. Coronary angiography showed a complete thrombotic cutoff of LAD, for which Tirofiban infusion was started to decrease thrombus burden. Repeat angiography on next day showed 80% lesion in proximal LAD for which she underwent revascularization with a drug-eluting stent. The patient later showed improvement in cardiac function at 8 months of follow-up.

Conclusions

The occurrence of ACS requiring percutaneous coronary intervention (PCI) in the setting of allergic reactions is rarely reported in the literature. One should be aware of the rare possibility of Kounis syndrome in the setting of hypersensitivity reaction when accompanying features of symptoms suggestive of coronary artery disease co-exists. When indicated, ECG monitoring and cardiac biomarkers in patients with allergic responses help to identify this rare and treatable condition.

Analysis of clinical characteristics of Kounis syndrome induced by contrast media

BACKGROUND

Understanding the relationship between contrast agents and Kounis syndrome (KS) is mainly based on case reports. The purpose of this research is to explore the clinical characteristics of contrast media induced KS.

METHODS

We searched for contrast-induced KS case reports through Chinese and English databases from 1991 to October 31, 2021.

RESULTS

A total of 26 patients (19 men and 7 women,) were included, with a median age of 60 years (range 30-83). The contrast agents that cause KS mainly included gadolinium-based contrast agent (7 cases), iodine-containing contrast media (12 cases). KS mainly occurred within 30 min after administration and mainly manifests as chest pain and allergic reactions. Electrocardiogram (ECG) mainly showed ST elevation. Echocardiography mainly revealed normal. Coronary angiography showed normal, coronary vasospasm, stent thrombosis, occlusion and stenosis. After treatment with steroids, antihistamines and anti-ischemic therapy, 24 patients recovered completely and 2 patients died.

CONCLUSIONS

KS is a rare adverse reaction of contrast media. Radiologists should recognize this rare but serious disease to ensure rapid diagnosis and proper management.

A Case of Kounis Syndrome Presenting as Coronary Artery Spasm Associated with Acetaminophen Infusion

Patient: Male, 38-year-old

Final Diagnosis: Myocardial Infarction

Symptoms: Chest discomfort • dyspnea • hypotension

Medication: —

Clinical Procedure: —

Specialty: Allergology • Cardiology

Allergic Acute Coronary Syndrome-Kounis Syndrome

Acute coronary syndrome (ACS) in the setting of an allergic/immunologic reaction is known as Kounis syndrome. It is an underdiagnosed and underrecognized disease entity. One must keep a high index of suspicions when managing a patient presenting with cardiac as well as allergic symptoms. There are 3 main variants to the syndrome. Treating the allergic reaction may alleviate the pain; however, ACS guidelines should be followed if cardiac ischemia is present.

Kounis Syndrome Secondary to Medicine-Induced Hypersensitivity

Introduction

Kounis syndrome is the concurrence of an acute coronary syndrome (ACS) caused by coronary vasospasms, acute myocardial infarctions, or stent thromboses in case of allergic or hypersensitivity reactions. Kounis syndrome is mediated by mast cells that interact with macrophages and T-lymphocytes, causing degranulation and inflammation with cytokine release. It is a life-threatening condition that has many trigger factors and is most commonly caused by medicines. Case Presentation. A 71-year-old male was admitted with a fever of five days' duration associated with cellulitis, for which he had been treated with clindamycin and flucloxacillin before admission. He was a diagnosed patient with hypertension and dyslipidemia five years ago. After taking the antibiotics, he had developed generalized itching followed by urticaria suggesting an allergic reaction. Therefore, he was admitted to the hospital. After admission, he developed an ischaemic-type chest pain associated with autonomic symptoms and shortness of breath. An immediate ECG was taken that showed ST-segment depressions in the chest leads V4–V6, confirmed by a repeat ECG. Troponin I was 8 ng/mL. Acute management of ACS was started, and prednisolone 10 mg daily dose was given. After complete recovery, the patient was discharged with aspirin, clopidogrel, atorvastatin, metoprolol, losartan, isosorbide mononitrate, and nicorandil. Prednisolone 10 mg daily dose was given for five days after discharge.

Conclusion

In immediate hypersensitivity, with persistent cardiovascular instability, Kounis syndrome should be considered, and an electrocardiogram and other appropriate assessments and treatments should be initiated. Prompt management of the allergic reaction and the ACS is vital for a better outcome of Kounis syndrome.

Hymenoptera heartaches -cardiac manifestation with hymenoptera stings, a retrospective study from a tertiary care hospital in South India

INTRODUCTION

Hymenoptera stings usually have a multitude of presentations from very subtle to life-threatening conditions. Various cardiac manifestations including Kounis syndrome often get missed due to lack of suspicion. The aim of the study was to describe the clinical profile of the cardiac etiologies associated with hymenoptera stings and review literature with focus on diagnosis and treatment strategies.

METHODOLOGY

A retrospective chart analysis was performed including all adult patients who had a hymenoptera sting during a two-year window (October 2018 - October 2020). Of these, patients with cardiac features were enrolled. A structured case record form was used to capture information like basic demography, clinical profile, and outcomes.

RESULTS

Thirteen cases presented with hymenoptera stings of which six cases had cardiac presentation and were considered. The most common presentations were breathlessness and generalised itching with only one patient complaining of chest pain. All patients(with available data) had ECG changes suggestive of ischemia and associated raised troponin levels with 2D echo changes. The diagnoses considered included Kounis syndrome, hypersensitivity myocarditis, and Takotsubo cardiomyopathy. Patients were managed conservatively with one patient undergoing a coronary angiography. All patients were stable at discharge.

CONCLUSION

Cardiac manifestations with hymenoptera stings although rare may complicate diagnosis and treatment.It should be borne in mind during assessment and standardised guidelines should be developed for ED treatment such as the one recommended in this study.

Metamizole-Induced Type I Kounis Syndrome

Kounis syndrome (KS) is defined as acute coronary syndrome (ACS) triggered by mast cell and platelet activation in the setting of allergic or anaphylactic insults. KS is a unique and complex cause of ACS and many cases may be missed due to its highly variable clinical manifestations. In this report, we present a case of KS type I triggered by metamizole in the absence of a previous history of allergy to this drug. Following the administration of metamizole, the patient developed generalized acute urticaria, chest pain and diaphoresis. Electrocardiography (ECG) showed ST-segment elevation suggestive of myocardial infarction complicated by ventricular tachycardia. No coronary disease was observed on coronary angiography. The cardiac manifestations of KS may be life-threatening, and so it is important to appropriately recognize and treat this condition.

LEARNING POINTS

Kounis syndrome (KS) diagnosis requires a high index of suspicion and should be considered in patients who present with acute coronary syndrome (ACS) soon after the administration of a new medication or possible allergic stimulus.Treatment should be administered carefully, since some drugs used to treat the cardiac manifestations of KS can worsen the allergic reaction.The prognosis is generally good with appropriate treatment, but some complications may occur, such as malignant arrhythmia.

Delayed Acute Coronary Syndrome Caused by Multiple Bee Stings: A Rare Case of Kounis Syndrome

A 51-year-old female patient was admitted to our hospital for medical evaluation and treatment of a syncopal episode following multiple bee stings. The syncopal episode was attributed to an allergic reaction and the patient was treated with intravenous hydration and anti-histamines. Twenty-four hours later, the patient manifested an acute coronary syndrome with chest discomfort, electrocardiographic disorders, and myocardial enzyme motility (including troponin). Coronary angiography was performed without revealing pathological findings and she was diagnosed with Kounis syndrome type I. The management of the patient included administration of single antiplatelet therapy combined with a calcium channel blocker (CCB). The patient follow-up was uncomplicated. In patients with Kounis syndrome type I undergoing a normal coronary angiography, in the absence of specific guidelines, single antiplatelet therapy and CCB may be a reasonable approach.

Epirubicin-induced Kounis syndrome

Background

Kounis syndrome is an acute coronary syndrome that appears in the setting of anaphylactic reaction or hypersensitivity. Many drugs and environmental exposures have been identified as potential offenders, and diagnosis and treatment can be challenging.

Case presentation

A 62-year-old man with recurrent bladder cancer underwent an intra-iliac artery epirubicin injection. After the injection, he developed chest pain and a systemic allergic reaction, with electrocardiographic alterations and elevated troponin-I levels. Emergent coronary angiography showed right coronary artery spasm and no stenosis of the other coronary arteries. This reaction was considered compatible with an allergic coronary vasospasm. A diagnosis of Kounis syndrome was made.

Conclusions

Kounis syndrome is common, but a prompt diagnosis is often not possible. This case is the first to suggest that an intraarterial epirubicin injection could potentially be one of its triggers. All physicians should be aware of the pathophysiology of this condition to better recognize it and start appropriate treatment; this will prevent aggravation of the vasospastic cardiac attacks and yield a better outcome.

The allergic myocardial infarction dilemma: is it the anaphylaxis or the epinephrine?

We highlight two distinct cases of myocardial infarction occurring concurrently with anaphylaxis at our centre in Singapore. The first case had cardiac symptoms and electrocardiogram changes concomitant with his anaphylaxis presentation, suggestive of Kounis syndrome, while the second case presented with anaphylaxis and only developed cardiac symptoms and electrocardiogram changes after treatment with intramuscular epinephrine, suggestive of epinephrine-induced myocardial infarction. Both these conditions are uncommon and under-recognised, and we review the current literature to compare the similarities and differences in their clinical manifestations, pathophysiology, and management. Kounis syndrome occurs secondary to mast cell degranulation ultimately resulting in coronary vasospasm, platelet activation and inflammatory response, whereas epinephrine causes platelet aggregation. Therefore, treatment priorities of Kounis syndrome are treatment of allergy, treatment of vasospasm, and treatment with anti-platelet therapy and revascularization if coronary plaques are present. For epinephrine-induced myocardial infarction, after epinephrine treatment is discontinued, considerations in management are re-vascularisation or pharmacotherapy. Further research will help with better understanding of both conditions and formulation of clinical management guidelines.

Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called 'Kounis-like' syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.

Insight into the Time Course of Type III Kounis Syndrome: A Case Report

BACKGROUND

Kounis syndrome is a rare condition that is characterized by the coexistence of acute coronary syndrome and allergic reactions; however, its time course remains unclear. We report a case of anaphylactic shock with subsequent development of ST-segment elevation myocardial infarction.

CASE REPORT

A 47-year-old man with food allergies presented to the emergency department of our hospital with breathing difficulties after eating bread. He had a history of angina and underwent stent implantation 3 years earlier. On examination, he was lethargic, disoriented, and in shock. He had a rash on his face and anterior chest wall, as well as severe itching and sweating. Anaphylaxis was diagnosed and, 3 min after presentation, 0.5 mg epinephrine was injected intramuscularly into the right thigh. Electrocardiography, which was recorded 2 min after the administration of epinephrine, was normal; however, chest pain developed suddenly 18 min later. Repeat electrocardiography showed ST-segment elevations, and emergency coronary angiography revealed total occlusion of the left anterior descending coronary artery (i.e., the previous stenting site). Recanalization of the left anterior descending coronary artery was achieved after repeated thrombus aspiration with difficulty, followed by stent implantation inside of the stent under the support of intra-aortic balloon pumping. The clinical course was uneventful. He was discharged and advised to avoid eating wheat and carry an epinephrine self-injection kit for anaphylaxis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The present case highlights the importance of recognizing Kounis syndrome in the management of anaphylactic shock because treatment may be difficult, particularly in patients with type III Kounis syndrome.

Utility of enhanced cardiac magnetic resonance imaging in Kounis syndrome: a case report

BACKGROUND

Kounis syndrome is the occurrence of acute coronary syndrome precipitated by an allergic reaction in the presence or absence of underlying coronary artery disease. The syndrome is explained by the effect of released inflammatory mediators on the coronary arteries and platelets.

CASE SUMMARY

We report an uncommon case of Kounis syndrome Type II in a 65-year-old man 24 h after being bitten by a hymenoptera. Clinical context, electrocardiogram, coronary angiography, and enhanced cardiac magnetic resonance imaging (MRI) imaging modality are presented.

DISCUSSION

Awareness and understanding of this syndrome is essential for starting early and appropriate therapy, thereby preventing life-threatening events. Accordingly, we highlight the importance of enhanced cardiac MRI to complete the assessment of this entity.

Near-fatal anaphylaxis with Kounis syndrome caused by Argas reflexus bite: a case report

Background

The pigeon tick Argas reflexus is a temporary parasite of pigeons. It bites during night hours and lies briefly on its prey, as long as it takes the blood meal. When pigeons are not accessible, ticks look for other hosts, invading nearby flats and biting humans.

Case presentation

We present the case of a woman aged 46 years who experienced severe anaphylaxis during the night which required emergency medical treatment, tracheal intubation and hospitalization in intensive care unit. Kounis syndrome was documented by transient ST depression and elevation of troponin. The allergological work up ruled out hypersensitivity to drugs, latex and foods containing alpha-gal, which is a cause of anaphylaxis. Basal serum tryptase was in normal range (8.63 ng/ml). When questioned about the presence of ticks, the patient brought into view various specimens of ticks that were recognized by an entomologist as Argas reflexus.

Conclusions

An in vitro diagnosis of allergy to Argas reflexus is currently not feasible because, though the major allergen Arg r 1 has been isolated, allergen extracts are not commercially available. Therefore, the diagnosis of anaphylaxis from Argas reflexus, when other causes of anaphylaxis are excluded, must rely only on history and clinical findings, as well as on the presence of pigeons and/or pigeon ticks in the immediate domestic environment.

Kounis syndrome uncovers severe coronary disease: an unusual case of acute coronary syndrome secondary to allergic coronary vasospasm

Acute coronary syndrome occurring during the course of a type I hypersensitivity reaction constitutes Kounis syndrome. We report a case of a 64-year-old man who presented with a non-ST elevation myocardial infarction and peripheral blood eosinophilia. He had rhinitis and constitutional symptoms for several days prior to presentation. Blood investigations revealed moderate eosinophilia and elevated IgE levels. A cardiac MRI showed generalised oedema with a subtle wall motion abnormality in basal inferior/inferolateral wall, and subendocardial high signal on late gadolinium enhancement suggesting a localised myocardial infarction. A coronary angiogram then revealed triple vessel disease. A diagnosis of Kounis syndrome was made. Within days of starting appropriate treatment, the patient’s eosinophil count returned to normal with improvement of clinical picture.

Contrast Media Induced Kounis Syndrome: A Case Report

Kounis syndrome is a rare anaphylactic reaction leading to coronary spasm, acute plaque rupture, or intrastent stenosis. Many types of medicine or environmental factors can potentially trigger Kounis syndrome by mast cell allergic reactions. In severe Kounis syndrome, reduced blood pressure or cardiac arrest may be accompanying symptoms. The treatment strategy for Kounis syndrome is usually difficult due to both cardiac dysfunction and allergic reactions. The delay to intervention to break the vicious circle may cause catastrophic complications. Therefore, early diagnosis is critical for physicians to outline detailed etiology for prevention and treat the cardiac and allergic symptoms in a timely manner. Here, we describe a case presenting rare severe Kounis syndrome with cardiac arrest which occurred after the administration of a contrast media.

Cardiogenic Shock due to Kounis Syndrome following Cobra Bite

Kounis syndrome is associated with mast cell activation resulting in acute coronary syndrome secondary to an allergic insult. Various drugs such as antibiotics, analgesics, and environmental exposures such as bee, wasp sting, and poison ivy are known to induce Kounis syndrome. A 68-year-old man admitted with a cobra bite on both hands to emergency care unit and sustained cardiorespiratory arrest. Electrocardiogram, taken 6 hours after the cardiac arrest, showed ST elevations in leads V₂ to V₅ suggestive of anterior ST elevation myocardial Infarction (STEMI). Serum Troponin was 10 ng/ml (control= <0.5). Serum IgE levels were significantly high (19155IU/ml, baseline 100). 2-Dimensional echocardiogram showed anterior and apical-septal hypokinesia with left ventricular ejection fraction of 30-35%. Coronary angiogram was normal. He remained hypotensive requiring inotropic and vasopressor support during ICU stay. This was a case of Kounis syndrome leading to cardiogenic shock secondary to Cobra (naja naja) bite. This is the only reported case of cobra bite causing Kounis syndrome and cardiogenic shock. Identification of the cause of myocardial infarction in snake envenomation is useful in the management as some of the drugs like adrenaline, morphine, and beta blockers may worsen the clinical syndrome if it is due to Kounis syndrome.

A case of Kounis syndrome presenting as coronary artery spasm associated with cefazolin-induced anaphylaxis during general anesthesia

Background

Kounis syndrome (KS) is defined as the occurrence of acute coronary syndrome (ACS) associated with an anaphylactic reaction, and there have only been a few reports of its occurrence under general anesthesia.

Case presentation

A 69-year-old woman underwent transurethral resection of a bladder tumor under general anesthesia. Cefazolin was administered intravenously after induction of general anesthesia. During the operation, we suspected ACS from sudden ST segment depression on electrocardiogram. The delayed onset of an erythematous rash reminded us of the anaphylactic reaction of KS. Coronary artery spasm of type 1 KS was diagnosed based upon the findings of coronary computerized tomography. Eleven days after the first surgery, the patient underwent nephroureterectomy uneventfully by a change in antibiotics. Finally, cefazolin proved to be the trigger drug by the intradermal test.

Conclusion

When electrocardiogram changes suggesting ACS occur during general anesthesia, it is necessary to take KS into consideration as a differential diagnosis.