Perioperative presentations of Kounis syndrome: a systematic literature review

Profound Coronary Vasospasm Associated with Intraoperative Ketamine Administration: A Case Report

We report a case of a 62-year-old woman with a decade-long history of atypical chest pain resulting in a largely negative cardiac workup, who developed significant angiographically demonstrated coronary vasospasm thought to be due to a small dose of intravenous ketamine. In patients with a history of atypical chest pain despite a reassuring cardiac evaluation, providers should carefully consider medications that may precipitate coronary vasospasm and be prepared to treat it accordingly.

Adrenaline, Takotsubo, Anaphylaxis, and Kounis Syndrome (ATAK) Complex Unveiled: Integrating Takotsubo and Kounis Syndromes in the Context of Chemotherapy-Related Anaphylaxis

The convergence of takotsubo and Kounis syndromes, collectively referred to as the "ATAK complex" (short for adrenaline, takotsubo, anaphylaxis, and Kounis syndrome), poses a unique and challenging clinical scenario, especially in the context of chemotherapy-related anaphylaxis. We present a case report involving a 63-year-old woman undergoing chemotherapy for endometrial adenocarcinoma who experienced anaphylactic symptoms during treatment. Immediate administration of epinephrine was followed by the emergence of ST elevation, a reduced left ventricular ejection fraction, and wall motion abnormalities indicative of stress-induced cardiomyopathy. Detailed investigations revealed normal coronary arteries, prompting further exploration into the intricacies of the ATAK complex. Notably, the administration of intravenous rather than intramuscular epinephrine was identified as a contributing factor. This case underscores the critical importance of recognizing and managing the ATAK complex promptly, emphasizing the need for refined diagnostic and treatment guidelines. The interplay between adrenaline, takotsubo, anaphylaxis, and Kounis syndrome necessitates a nuanced approach, urging healthcare professionals to exercise caution and adhere to recommended administration routes. Increased awareness of the ATAK complex is imperative for optimizing patient outcomes and guiding therapeutic interventions in similar clinical scenarios. Further research is warranted to elucidate the underlying mechanisms and refine strategies for the effective management of this intricate syndrome.

Cardiac Arrest Due to Kounis Syndrome Following Cephazolin Administration During Surgery Under Local Anesthesia

The Kounis syndrome is described as the co-occurrence of allergic responses brought on by mast cell activation and acute coronary syndromes. We present a case of Kounis syndrome leading to cardiac arrest following the cephazolin sodium administration during the surgical resection of basal cell carcinoma. An 87-year-old woman was diagnosed with basal cell cancer. She received surgical excision of the tumor while anesthetized with lidocaine hydrochloride and 1% epinephrine. This patient began to itch around five minutes after cefazolin (CEZ) administration and eventually experienced cardiac arrest following diffuse rashes that spread throughout her body and edema in her eyelids. In line with the response, the electrocardiogram (ECG) also showed an elevated ST segment in V1-6, leading to possibly the diagnosis of Kounis syndrome. We also review the literature on Kounis syndrome following CEZ administration.

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

RATIONALE

Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome.

PATIENT CONCERNS

A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach.

DIAGNOSES

On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome.

INTERVENTIONS

Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min.

OUTCOMES

After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae.

LESSONS

If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.

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.

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.