Delayed Kounis syndrome and acute renal failure after wasp sting

Exploring Variations in Etiology and Clinical Presentations of Kounis Syndrome Across Pediatric and Adult Populations: A Comprehensive Review

Kounis syndrome (KS), recognized as a rare yet significant form of acute coronary syndrome precipitated by allergy-mediated mechanisms, poses diagnostic challenges due to its varied clinical presentations and under-recognition. Despite its relevance across diverse populations, comprehensive insights into age-specific characteristics and management remain limited. The analysis of 420 studies yielded a total of 466 case reports of Kounis syndrome, categorized into pediatric (n = 31) and adult (n = 435) populations. After rigorous screening, 330 adult and 20 pediatric case reports were included for further analysis. Triggering factors were identified, with drugs (other) being the most prevalent in both groups. The breakdown of triggering factors, such as drugs (antibiotics), bee/wasp stings, and contrast media, was elucidated. Variations in presenting symptoms, diagnostic investigations, and treatment modalities between pediatric and adult populations were observed. Notably, all pediatric cases were diagnosed with subtype I Kounis syndrome and demonstrated favorable outcomes without any reported fatalities, whereas adult cases exhibited a broader range of Kounis subtypes. Mortality was recorded solely in adult case reports, with no fatalities reported among pediatric cases. These findings underscore the importance of understanding the nuances in the clinical presentation and management of Kounis syndrome across different age groups.

Clinical manifestations of wasp stings: a case report and a review of literature

Background

Wasp stinging, a neglected tropical entity can have a myriad of local and systemic effects. We present a case of multi-organ injury following multiple wasp stings and a review of literature on the systemic manifestations of wasp stings.

Case presentation

A 48-year-old Sri Lankan male who suffered multiple wasp stings, developed an anaphylactic shock with respiratory failure, which was treated with adrenaline and mechanical ventilation. Within the next 2 days the patient developed acute fulminant hepatitis, stage III acute kidney injury, rhabdomyolysis, haemolysis and thrombocytopenia. The patient was treated in the intensive care unit with ionopressors and continuous renal replacement therapy (CRRT). Haemoadsorbant therapy was used in adjunct with CRRT. There was a gradual recovery of the organ functions over the 1st week. However, the patient succumbed to fungal sepsis on the 16th day despite treatment. We conducted a literature review to identify the various clinical manifestations of wasp stinging. Wasp venom contains enzymes, amines, peptides and other compounds. These proteins can cause type 1 hypersensitive reactions ranging from local skin irritation to anaphylactic shock. Furthermore, the toxins can cause direct organ injury or delayed hypersensitivity reactions. The commonly affected organs are the kidneys, liver, and muscles. The effect on the haematological system manifests as coagulopathy and/or cytopenia. The heart, nervous system, lungs, intestines and skin can be affected rarely. Treatment is mainly supportive.

Conclusion

In conclusion, wasp envenomation can result in multi-organ injury and attention should be paid in doing further research and establishing evidence-based treatment practices.

Tako-tsubo cardiomyopathy in clinical toxinology: A systematic review

Tako-tsubo cardiomyopathy (TTC) is a transient left ventricular dysfunction, normally triggered by emotional or physical stress, although it is also associated with to use of drugs, drug abuse, or some intoxications. In addition, TTC has been reported in some case reports derived from the exposure of patients to animal venoms, toxins or poisons, or bacterial infections. However, to date, a systematic assessment of TTC in clinical toxinology is lacking. Therefore the aim of this study was to collect and integrate the available information about TTC in clinical toxinology. After our search strategy, 19 articles were retrieved, resulting in 20 case reports. Most cases occurred in women (75.0%). The venomous species that trigger TTC are bee/wasp, including probable Africanized honey bee and Vespa orientalis (15.0%), scorpions (Tytius serrulatus and Androctonus australis, 15.0%), a spider (Latrodectus tredecimguttatus, 5.0%), snakes (Gloydius blomhofii and Naja nivea, 10.0%), Clostridium sp (C. tetani, C. botulinum and C. difficile, 45.0%) and jellyfish (Pelagia noctiluca and Carukia barnesi, 10.0%). Among the affected people there were two deaths. In all case reports authors diagnosed TTC by using the combination of some of the following strategies: clinical findings, echocardiography, magnetic cardiac resonance, electrocardiogram changes and/or the increased plasma levels of cardiac damage biomarkers. In most cases images were available. We hypothesized the possible mode of action of venoms, toxins or poisons to induce TTC, however other mechanisms may exist, but they have not been described yet. Therefore, further studies are needed. In some cases, venoms, toxins, or poisons might cause catecholamine discharge either directly or indirectly, therefore, this was suggested as the trigger of TTC. Finally, the appearance of TTC should be considered in clinical toxinology.

Severe Tetanus Complicated by Takotsubo Cardiomyopathy

A 70-year-old woman was admitted to our hospital due to difficulty in moving her limbs. She had trismus and a necrotic and contaminated wound in her left lower leg. A diagnosis of tetanus was confirmed and intensive care was started. On the second day, her blood pressure fell and a ST segment elevation on electrocardiography (ECG) was detected. She was diagnosed with takotsubo cardiomyopathy by echocardiogram and improved undergoing conservative therapy.

Capecitabine-induced ventricular fibrillation arrest: Possible Kounis syndrome

We report the case of capecitabine-induced ventricular fibrillation arrest, possibly secondary to type I Kounis syndrome. A 47-year-old man with a history of T3N1 moderately differentiated adenocarcinoma of the colon, status-post sigmoid resection, was started on adjuvant capecitabine approximately five months prior to presentation of cardiac arrest secondary to ventricular fibrillation. An electrocardiogram (EKG) revealed ST segment elevation on the lateral leads and the patient was taken emergently to the cardiac catheterization laboratory. The catheterization revealed no angiographically significant stenosis and coronary artery disease was ruled out. After ruling out other causes of cardiac arrest, the working diagnosis was capecitabine-induced ventricular fibrillation arrest. As such, an inflammatory work up was sent to evaluate for the possibility of a capecitabine hypersensitivity, or Kounis syndrome, and is the first documented report in the literature to do so when evaluating Kounis syndrome. Immunoglobulin E (IgE), tryptase, and C-reactive protein were normal but histamine, interleukin (IL)-6, and IL-10 were elevated. Histamine elevation supports the suspicion that our patient had type I Kounis syndrome. Naranjo adverse drug reaction probability scale indicates a probable adverse effect due to capecitabine with seven points. A case of capecitabine-induced ventricular fibrillation arrest is reported, with a potential for type 1 Kounis syndrome as an underlying pathology supported by immunologic work up.

Transient reverse takotsubo cardiomyopathy following a spider bite in Greece: a case report

Black widow spider is endemic in the Mediterranean area and although envenomations are rare, may occasionally lead to death. We present a case of a 64-year-old female developing a rare variant of takotsubo, stress-induced, cardiomyopathy after a spider bite. This resulted in acute heart failure within 24  hours of the bite. With medical treatment and supportive care, the patient's clinical condition improved. Reverse takotsubo cardiomyopathy was diagnosed by echocardiography, which was transient. Clinical and echocardiographic findings have been completely resolved on follow-up 46 days later. Reverse takotsubo cardiomyopathy has not been yet described following a spider bite. Doctors in the emergency department of endemic countries should be familiar with this potential complication.