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Maadarani O, Bitar Z, Shoeb S, Alsaddah J. From Wellens To Kounis Syndrome: An Unlucky Patient. Eur J Case Rep Intern Med 2020; 7:001689. [PMID: 32908826 DOI: 10.12890/2020_001689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/05/2022] Open
Abstract
Wellens syndrome (WS) is identified by ECG changes in the precordial leads after resolution of angina chest pain. WS indicates critical stenosis of the proximal left anterior descending (LAD) artery. On the other hand, Kounis syndrome (KS) is an allergic reaction to various substances resulting in acute coronary syndrome. Contrast media can trigger the allergic reaction associated with KS. We describe a patient with WS who developed an allergic reaction to contrast media after percutaneous coronary intervention and experienced recurrent myocardial infarction on re-exposure. LEARNING POINTS Despite its rarity, physicians and radiologists should be aware of Kounis syndrome triggered by contrast media so it can be rapidly diagnosed and treated.The initial target of the prevention and treatment of KS is avoidance of the precipitating stimulus or allergen.There are three KS variants: angina due to allergic coronary spasm, allergic myocardial infarction and allergy-induced stent thrombosis.
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Affiliation(s)
- Ossama Maadarani
- Internal Medicine Department, Ahmadi Hospital - Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Zouheir Bitar
- Internal Medicine Department, Ahmadi Hospital - Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Sania Shoeb
- Internal Medicine Department, Al Salam Hospital, Kuwait
| | - Jadan Alsaddah
- Department of Cardiology, Chest Diseases Hospital, Kuwait
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Dardeer A, Shallik N. Perioperative anaphylaxis: A new visit to an old topic. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Shibuya K, Kasama S, Funada R, Katoh H, Tsushima Y. Kounis syndrome induced by contrast media: A case report and review of literature. Eur J Radiol Open 2019; 6:91-96. [PMID: 30805421 PMCID: PMC6374503 DOI: 10.1016/j.ejro.2019.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 12/21/2022] Open
Abstract
Kounis syndrome (KS) is an acute coronary disorder associated with anaphylactic reactions. The purpose of this report is to identify the features of KS triggered by contrast media on the basis of our experience and from literature review. We have described a case and literature review of KS triggered by injection of contrast media. Including the present case, we reviewed eleven cases of KS. Six cases developed KS in diagnostic radiology departments. KS could be induced by intravenous injection of contrast media in the radiology department. Radiologists should recognize this critical condition to ensure appropriate management.
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Affiliation(s)
- Kei Shibuya
- Department of Diagnostic and Interventional Radiology, Gunma University Hospital, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan.,Gunma University Heavy Ion Medical Center, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan
| | - Shu Kasama
- Department of Medicine and Biological Science (Cardiovascular Medicine), Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan
| | - Ryuichi Funada
- Department of Medicine and Biological Science (Cardiovascular Medicine), Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan
| | - Hiroyuki Katoh
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan
| | - Yoshito Tsushima
- Department of Diagnostic and Interventional Radiology, Gunma University Hospital, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan
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Hamdi I, Chourabi C, Jabloun TY, Ghommidh M, Lahidheb D, Fehri W, Haouala H. Samter–Beer triad presenting as Kounis type I variant of syndrome. J Saudi Heart Assoc 2018; 30:290-293. [PMID: 29983505 PMCID: PMC6026398 DOI: 10.1016/j.jsha.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/04/2018] [Accepted: 03/14/2018] [Indexed: 11/19/2022] Open
Affiliation(s)
- Imen Hamdi
- Cardiology Department, Military Hospital of Tunis, Tunis TunisiaaTunisia
- Corresponding author at: Cardiology Department, Military Hospital of Tunis, Mont Fleury, 1008 Tunis, Tunisia.
| | - Chadia Chourabi
- Cardiology Department, Military Hospital of Tunis, Tunis TunisiaaTunisia
| | | | - Mehdi Ghommidh
- Cardiology Department, Military Hospital of Tunis, Tunis TunisiaaTunisia
| | - Dhaker Lahidheb
- Cardiology Department, Military Hospital of Tunis, Tunis TunisiaaTunisia
| | - Wafa Fehri
- Cardiology Department, Military Hospital of Tunis, Tunis TunisiaaTunisia
| | - Habib Haouala
- Cardiology Department, Military Hospital of Tunis, Tunis TunisiaaTunisia
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Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome. Int J Cardiol 2017; 232:1-4. [DOI: 10.1016/j.ijcard.2017.01.124] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/30/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
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Renda F, Marotta E, Landoni G, Belletti A, Cuconato V, Pani L. Kounis syndrome due to antibiotics: A global overview from pharmacovigilance databases. Int J Cardiol 2016; 224:406-411. [PMID: 27684599 DOI: 10.1016/j.ijcard.2016.09.066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/16/2016] [Accepted: 09/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Kounis syndrome (KS) is characterized by concurrent presence of anaphylactic and cardiac components. Available evidence suggests that antibiotics are frequently associated to KS. We therefore analyzed KS cases associated with antibiotics use from the two largest pharmacovigilance databases. METHODS Two pharmacovigilance databases, EudraVigilance and VigiLyze, were searched for cases reporting the adverse reaction "Kounis Syndrome" with antibiotics as suspected active substance. We analyzed the period from December 1st, 2001 to February 16th, 2016. For the most reported active substance, proportional reporting ratio (PRR) was calculated. RESULTS A total of 10 cases of KS associated with antibiotic use were retrieved from EudraVigilance database. Mean patients' age was 58.2years and 70% were male. The most frequently reported suspected antibiotic was the combination amoxicillin/clavulanic acid (four cases). VigiLyze database reported 13 KS cases associated to antibiotics. Mean age was 56years and 61% of patients were male. The most frequently reported antibiotic was again the combination amoxicillin/clavulanic acid (five cases). Seven duplicate cases were identified, leaving a total of 16 cases of KS, with six of them associated to amoxicillin/clavulanic acid use. The PRR value for amoxicillin/clavulanic acid against other kinds of antibiotics was 2.62 considering EudraVigilance data and 1.61 considering VigiLyze data. CONCLUSIONS This analysis provided a complete picture of the cases of KS associated with antibiotic use and identified a possible association between amoxicillin/clavulanic acid and KS. Since the number of cases is low, especially considering its wide use, further analyses are needed to confirm the association.
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Affiliation(s)
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Luca Pani
- Italian Medicines Agency, Rome, Italy
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Alsancak Y, Ali S, Duran M, Polat M, Sivri S, Bilge M. A rare case of Kounis syndrome provoked by mad honey poisoning. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2016. [DOI: 10.1016/j.ijcac.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Renda F, Landoni G, Trotta F, Piras D, Finco G, Felicetti P, Pimpinella G, Pani L. Kounis Syndrome: An analysis of spontaneous reports from international pharmacovigilance database. Int J Cardiol 2016; 203:217-20. [DOI: 10.1016/j.ijcard.2015.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/22/2015] [Accepted: 10/03/2015] [Indexed: 12/30/2022]
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Scherbak D, Lazkani M, Sparacino N, Loli A. Kounis syndrome: a stinging case of ST-elevation myocardial infarction. Heart Lung Circ 2014; 24:e48-50. [PMID: 25547529 DOI: 10.1016/j.hlc.2014.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/15/2014] [Accepted: 11/18/2014] [Indexed: 11/28/2022]
Abstract
Kounis syndrome is not a rare but an infrequently diagnosed non-thrombogenic cause of angina or myocardial infarction triggered by the release of inflammatory mediators following an allergic or anaphylactic reaction. This so-called "allergic angina" is seen in the setting of anaphylactic reactions and is believed to be due to mast cell release causing coronary vasospasm. The treatment of such cases is often with epinephrine, which has also been described in the literature as another rare cause of coronary vasospasm. We present a case of Kounis syndrome seen in a 46 year-old male who suffered two bee stings while landscaping in his yard. He developed an anaphylactic reaction and was promptly treated with IM epinephrine injection by paramedics at arrival and developed marked ST elevations on EKG in the inferior leads with reciprocal ST depressions in the anterior leads. His troponin peaked at 13 ng/mL and tryptase level was 15 ng/mL (normal <10 ng/mL). Coronary catheterisation showed non-diseased coronary arteries and a normal ejection fraction without evidence of vasospasm. He was afterwards treated with an epinephrine drip for distributive shock. Interestingly this syndrome was not provoked when re-challenged with this therapy, suggestive of an allergic reaction rather than epinephrine as the aetiology of his presumed vasospasm. This patient's ST segment elevation and troponin elevation was due to Kounis syndrome. Awareness that anaphylactic reactions can lead to Kounis syndrome can lead to prompt appropriate treatment for this life threatening condition.
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Affiliation(s)
- Dmitriy Scherbak
- Department of Internal Medicine, Banner Good Samaritan Medical Center, Phoenix AZ, 85006.
| | - Mohamad Lazkani
- Department of Cardiology, Banner Good Samaritan Medical Center, Phoenix AZ, 85006
| | - Nick Sparacino
- Department of Critical Care Medicine, Banner Good Samaritan Medical Center, Phoenix AZ, 85006
| | - Akil Loli
- Department of Cardiology, Banner Good Samaritan Medical Center, Phoenix AZ, 85006
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A Case with Repeated Recurrent Acute Coronary Syndrome due to Pseudoephedrine Use: Kounis Syndrome. Case Rep Med 2014; 2014:742905. [PMID: 25435880 PMCID: PMC4243469 DOI: 10.1155/2014/742905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/16/2014] [Indexed: 11/18/2022] Open
Abstract
Allergic reaction-associated acute coronary syndrome picture is defined as Kounis syndrome. Although drug use is the most common cause of allergic reaction, foods and environmental factors may also play a role in the etiology. Herein, a case with acute coronary syndrome that developed two times at 8-month interval due to pseudoephedrine use for upper respiratory tract infection is presented.
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Prajapati JS, Virpariya KM, Thakkar AS, Abhyankar AD. A case of type I variant Kounis syndrome with Samter-Beer triad. World J Cardiol 2013; 5:112-114. [PMID: 23675559 PMCID: PMC3653012 DOI: 10.4330/wjc.v5.i4.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 03/04/2013] [Accepted: 03/15/2013] [Indexed: 02/06/2023] Open
Abstract
Kounis syndrome is defined as the coexistence of acute coronary syndromes with situations associated with allergy or hypersensitivity, as well as anaphylactic or anaphylactoid reactions, to a variety of medical conditions, environmental and medication exposures. We report a case of Kounis-Zavras syndrome type I variant in the setting of aspirin-induced asthma, or the Samter-Beer triad of asthma, nasal polyps and aspirin allergy. When there is a young individual with no predisposing factors of atherosclerosis and apparent coronary lesion, with or without electrocardiography and biochemical markers of infarction, the possibility of Kounis syndrome should be kept in mind.
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Kounis NG, Mazarakis A, Tsigkas G, Giannopoulos S, Goudevenos J. Kounis syndrome: a new twist on an old disease. Future Cardiol 2012; 7:805-24. [PMID: 22050066 DOI: 10.2217/fca.11.63] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation, such as allergies or hypersensitivity and anaphylactic or anaphylactoid insults that can involve other interrelated and interacting inflammatory cells behaving as a 'ball of thread'. It is caused by inflammatory mediators such as neutral proteases including tryptase and chymase, arachidonic acid products, histamine, platelet activating factor and a variety of cytokines and chemokines released during the activation process. Platelets with FCεRI and FCεRII receptors also participate in the above cascade. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three reported variants of this syndrome. Kounis syndrome is a ubiquitus disease that represents a magnificent natural paradigm and nature's own experiment, in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture. Kounis syndrome can complicate anesthesia, vaccination, medical therapy and stent implantation and it seems to be associated with coronary allograft vasculopathy and takotsubo syndrome, it can often be confused with hypersensitivity myocarditis and can be the cause of unexplained sudden death. Kounis syndrome has revealed that the same mediators released from the same inflammatory cells are present in acute coronary events of nonallergic etiology. These cells are not only present in the culprit region before plaque erosion or rupture but they release their contents just before an actual coronary event. Therefore, does Kounis syndrome represent a magnificent natural paradigm and nature's own experiment in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture showing a novel way towards our effort to prevent acute coronary syndromes? Drugs, substances targeting the stem cell factor that is essential for mast cell development, proliferation, survival, adhesion and homing as well as monoclonal antibodies and natural molecules that protect mast cell surface and stabilize mast cell membrane could emerge as novel therapeutic ways capable to prevent acute coronary and acute cerebrovascular events.
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Affiliation(s)
- Nicholas G Kounis
- Department of Cardiology, Agios Andreas State General Hospital, Patras, Greece.
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Rico Cepeda P, Palencia Herrejón E, Rodríguez Aguirregabiria MM. [Kounis syndrome]. Med Intensiva 2011; 36:358-64. [PMID: 22154226 DOI: 10.1016/j.medin.2011.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/01/2011] [Accepted: 10/09/2011] [Indexed: 12/21/2022]
Abstract
Kounis syndrome was described in 1991 by Kounis and Zavras as the coincidental occurrence of acute coronary syndromes with allergic reactions (anaphylactic or anaphylactoid). Today, allergic angina and allergic myocardial infarction are referred to as Kounis syndrome, and the latter has been reported in association with a variety of drugs, insect stings, food, environmental exposures and medical conditions, among other factors. The incidence is not known, as most of the available information comes from case reports or small case series. In this article, the clinical aspects, diagnosis, pathogenesis, related conditions and therapeutic management of the syndrome are discussed.
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Affiliation(s)
- P Rico Cepeda
- Servicio de Medicina Intensiva, Hospital Universitario Infanta Leonor, Madrid, España.
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Coronary stent implantation, eosinophils and the Kounis hypersensitivity associated acute coronary syndrome. Atherosclerosis 2011; 217:67-9. [DOI: 10.1016/j.atherosclerosis.2011.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 02/01/2011] [Indexed: 02/06/2023]
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