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Forzese E, Pitrone C, Cianci V, Sapienza D, Ieni A, Tornese L, Cianci A, Gualniera P, Asmundo A, Mondello C. An Insight into Kounis Syndrome: Bridging Clinical Knowledge with Forensic Perspectives. Life (Basel) 2024; 14:91. [PMID: 38255706 PMCID: PMC10817466 DOI: 10.3390/life14010091] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or hypersensitivity reactions. Incidence rates vary, with studies reporting 19.4 per 100.000 among all admissions and 3.4% among allergy patients. This review explores the expanding understanding of KS, encompassing various manifestations, and focusing on both clinical data and forensic findings useful in performing a diagnosis. The pathophysiology of this syndrome involves a complex interplay between allergic reactions and the cardiovascular system. Mast cell activation, histamine release, leukotrienes, cytokines, and platelet activation can contribute to coronary events. Three types of classification systems (allergic angina, allergic myocardial infarction, allergic stent thrombosis) aid in categorizing presentations. The diagnosis of KS relies on clinical presentation, laboratory findings, and imaging. Postmortem assessment of KS is based on the integration of circumstantial data, autopsy, and histological findings. Biochemical and immunohistochemical analyses also contribute to postmortem diagnosis. In conclusion, a combined, multidisciplinary approach should be used to ease the diagnostic process, which is crucial for forensic practitioners in confirming KS occurrence.
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Affiliation(s)
- Elena Forzese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Claudia Pitrone
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Vincenzo Cianci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Daniela Sapienza
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Antonio Ieni
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, Section of Pathology, University of Messina, 98125 Messina, Italy;
| | - Lorenzo Tornese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Alessio Cianci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli—IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy;
| | - Patrizia Gualniera
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Alessio Asmundo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
| | - Cristina Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (E.F.); (C.P.); (D.S.); (L.T.); (P.G.); (C.M.)
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Lambert K, Tse R, Tettamanti C, Scarpelli MP, Rousseau G, Bonsignore A, Palmiere C. Postmortem IgE determination in coronary artery disease. J Forensic Leg Med 2019; 62:1-6. [PMID: 30599216 DOI: 10.1016/j.jflm.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 11/12/2018] [Accepted: 12/20/2018] [Indexed: 01/08/2023]
Abstract
Allergic, IgE-mediated inflammation is thought to play a role in atherogenesis and atherosclerotic disease progression. In this study, total IgE and mast cell tryptase were measured in a series of forensic autopsy cases including non-allergic cardiac deaths (14 cases with minimal or no coronary atherosclerosis, 14 cases with significant coronary artery atherosclerosis without acute coronary thrombosis, and 14 cases with significant coronary artery atherosclerosis and acute coronary thrombosis or myocardial infarction) and non-allergic non-cardiac deaths (21 cases with death due to hanging and 21 cases with death due to intracranial gunshot wounds), in order to correlate laboratory results with morphological findings and compare them to conclusions reported in the clinical setting. In cardiac death cases, postmortem serum total IgE levels were increased in 7 out of 42 cases and mast cell tryptase levels were increased in 3 out of 42 cases. In non-cardiac death cases, postmortem serum total IgE levels were not increased in 39 out of 42 cases and mast cell tryptase levels were not increased in any of these cases. These preliminary findings seem to indicate that a portion of coronary deaths characterized by coronary artery atherosclerosis of various severities are also characterized by increased total IgE and mast cell tryptase levels, thus corroborating the data previously reported in both clinical and forensic literature on this topic as well as the necessity of combining morphological investigations focusing on the heart and coronary arteries with biochemical analyses.
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Affiliation(s)
- Karine Lambert
- CURML, Centre Universitaire Romand de Médecine Légale, Lausanne University Hospital, Chemin de La Vulliette 4, 1000, Lausanne 25, Switzerland
| | - Rexson Tse
- Department of Forensic Pathology, LabPLUS, Auckland City Hospital, Auckland, 1148, New Zealand
| | - Camilla Tettamanti
- Departmental Section of Forensic and Legal Medicine and School of Specialization in Legal Medicine, University of Genova, Via de Toni 12, 16132, Genova, Italy
| | - Maria Pia Scarpelli
- CURML, Centre Universitaire Romand de Médecine Légale, Lausanne University Hospital, Chemin de La Vulliette 4, 1000, Lausanne 25, Switzerland
| | - Guillaume Rousseau
- Département de Biochimie et Génétique, Centre Hospitalier Universitaire D'Angers, Angers, France; Service de Médecine Légale et Pénitentiaire, Centre Hospitalier Universitaire D'Angers, Angers, France
| | - Alessandro Bonsignore
- Departmental Section of Forensic and Legal Medicine and School of Specialization in Legal Medicine, University of Genova, Via de Toni 12, 16132, Genova, Italy
| | - Cristian Palmiere
- CURML, Centre Universitaire Romand de Médecine Légale, Lausanne University Hospital, Chemin de La Vulliette 4, 1000, Lausanne 25, Switzerland.
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Abstract
Aim To review the available literature pertaining to fatalities following vaccine administration and, in particular, cases of vaccine-related fatal anaphylaxis. Method The MEDLINE database was systematically searched up to March 2016 to identify all relevant articles pertaining to fatal cases of anaphylaxis following vaccine administration. Results Six papers pertaining to fatal anaphylaxis following vaccination were found relevant. Mast cell tryptase and total IgE concentration was assessed exclusively in one case. Laryngeal edema was not detected in any of these cases, whereas eosinophil or mast cell infiltration was observed in lymphoid organs. In one case, immunohistochemical investigations using anti-tryptase antibodies allowed pulmonary mast cells and degranulating mast cells with tryptase-positive material outside to be identified. Conclusion In any suspected IgE-mediated fatal anaphylactic cases, biochemical investigations should be systematically performed for forensic purposes. Splenic tissue should be routinely sampled for immunohistochemical investigations in all suspected anaphylaxis-related deaths and mast cell/eosinophil infiltrations should be systematically sought out in the spleen, myocardium, and coronary artery wall. The hypothesis of fatal anaphylaxis following vaccination should be formulated exclusively when circumstantial data, available medical records, laboratory investigations, and autopsy or histology findings converge in a consistent pattern. The reasonable exclusion of alternative causes of death after all postmortem investigations is also imperative in order to establish or rule out a cause-and-effect relationship between vaccine administration and any presumptive temporarily-related death.
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Affiliation(s)
- Cristian Palmiere
- Cristian Palmiere, CURML, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland,
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In Response to Xylocopa tranquebarica Fatal Stinging by Kularatne et al. Wilderness Environ Med 2016; 27:438-9. [DOI: 10.1016/j.wem.2016.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 04/29/2016] [Indexed: 11/21/2022]
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Palmiere C. Postmortem diagnosis of drug-induced anaphylactic death. J Forensic Leg Med 2016; 41:28-9. [DOI: 10.1016/j.jflm.2016.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 12/30/2022]
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