Acute coronary syndrome secondary to allergic coronary vasospasm (Kounis Syndrome): a case series, follow-up and literature review

The curious case of Kounis syndrome: exploring clinical manifestations and management in the presence of nonobstructive coronary arteries

Kounis syndrome, an allergic hypersensitivity coronary disorder, is a rare but potentially life-threatening condition triggered by various allergens, including medications. We present the case of a 41-year-old male with no prior cardiac history, who developed Kounis syndrome following vancomycin administration for suspected cellulitis. The patient initially presented with rash, fever, and malaise, which progressed to chest discomfort associated with diaphoresis and elevated troponin levels. Diagnostic evaluations, including electrocardiographic changes and coronary angiography, confirmed a diagnosis of type I Kounis syndrome. This case adds to the limited literature on vancomycin-induced Kounis syndrome, and underscores the importance of considering this diagnosis in patients with myocardial damage following exposure to potential allergens.

Ceftriaxone-induced Kounis syndrome: A case report and review of the literature

Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.

Unexpected cause of Kounis syndrome: hypersensitivity reaction to omeprazole

Kounis syndrome is a rare type of acute coronary syndrome (ACS) that occurs as a result of an allergic or anaphylactic reaction. Kounis syndrome can be induced by various medications including antibiotics, proton pump inhibitors, antihypertensive medications, corticosteroids, and antineoplastic medications. Additionally, cases of Kounis syndrome associated with lansoprazole and pantoprazole have been previously reported in the literature. In this report, we present a case of Kounis syndrome associated with omeprazole use, and discuss the need for a high index of suspicion as it is often underrecognised.

Kounis Syndrome: Bee Sting-Induced Acute Myocardial Infarction

Acute coronary syndrome or ST-elevation myocardial infarction that develops as a hypersensitive reaction following exposure to an allergen, such as chemicals or bee or wasp stings, is known as Kounis syndrome (KS). Based on angiographic characteristics, three kinds of KS have been identified. Multiple bee stings typically result in localized allergic reactions and anaphylaxis, but they can also occasionally induce severe systemic toxic reactions. Here, a case of KS in a 50-year-old male presented with swelling on the face and upper limbs and breathing difficulties resulting from bee stings which led to myocardial infarction. The risk of KS should be considered by the physician at the primary level in all situations involving multiple bee bites.

Identification of the biological processes, immune cell landscape, and hub genes shared by acute anaphylaxis and ST-segment elevation myocardial infarction

Background: Patients with anaphylaxis are at risk for ST-segment elevation myocardial infarction (STEMI). However, the pathological links between anaphylaxis and STEMI remain unclear. Here, we aimed to explore shared biological processes, immune effector cells, and hub genes of anaphylaxis and STEMI. Methods: Gene expression data for anaphylactic (GSE69063) and STEMI (GSE60993) patients with corresponding healthy controls were pooled from the Gene Expression Omnibus database. Differential expression analysis, enrichment analysis, and CIBERSORT were used to reveal transcriptomic signatures and immune infiltration profiles of anaphylaxis and STEMI, respectively. Based on common differentially expressed genes (DEGs), Gene Ontology analysis, cytoHubba algorithms, and correlation analyses were performed to identify biological processes, hub genes, and hub gene-related immune cells shared by anaphylaxis and STEMI. The robustness of hub genes was assessed in external anaphylactic (GSE47655) and STEMI (GSE61144) datasets. Furthermore, a murine model of anaphylaxis complicated STEMI was established to verify hub gene expressions. The logistic regression analysis was used to evaluate the diagnostic efficiency of hub genes. Results: 265 anaphylaxis-related DEGs were identified, which were associated with immune-inflammatory responses. 237 STEMI-related DEGs were screened, which were involved in innate immune response and myeloid leukocyte activation. M0 macrophages and dendritic cells were markedly higher in both anaphylactic and STEMI samples compared with healthy controls, while CD4⁺ naïve T cells and CD8⁺ T cells were significantly lower. Enrichment analysis of 33 common DEGs illustrated shared biological processes of anaphylaxis and STEMI, including cytokine-mediated signaling pathway, response to reactive oxygen species, and positive regulation of defense response. Six hub genes were identified, and their expression levels were positively correlated with M0 macrophage abundance and negatively correlated with CD4⁺ naïve T cell abundance. In external anaphylactic and STEMI samples, five hub genes (IL1R2, FOS, MMP9, DUSP1, CLEC4D) were confirmed to be markedly upregulated. Moreover, experimentally induced anaphylactic mice developed impaired heart function featuring STEMI and significantly increased expression of the five hub genes. DUSP1 and CLEC4D were screened as blood diagnostic biomarkers of anaphylaxis and STEMI based on the logistic regression analysis. Conclusion: Anaphylaxis and STEMI share the biological processes of inflammation and defense responses. Macrophages, dendritic cells, CD8⁺ T cells, and CD4⁺ naïve T cells constitute an immune cell population that acts in both anaphylaxis and STEMI. Hub genes (DUSP1 and CLEC4D) identified here provide candidate genes for diagnosis, prognosis, and therapeutic targeting of STEMI in anaphylactic patients.

Kounis Syndrome: A Rare Case of Allergic Angina Secondary to Loxoscelism

Kounis syndrome or allergic angina is characterized by a sudden transient or permanent myocardial dysfunction caused by inflammatory mediators such as histamine, leukotrienes, platelet-activating factor, neutral proteases, and a number of cytokines and chemokines. Herein, we discuss a case of Kounis syndrome, which was brought on by loxoscelism.

Kounis Syndrome Associated With the Use of Diclofenac

BACKGROUND

Diclofenac is a widely used analgesic, anti-inflammatory, antipyretic drug. In several case reports, its use was associated with the occurrence of Kounis syndrome. The aim of this review was to investigate and summarize published cases of Kounis syndrome suspected to be associated with the use of diclofenac.

METHODS

Electronic searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and the Serbian Citation Index.

RESULTS

Twenty publications describing the 20 patients who met inclusion criteria were included in the systematic review. Specified patient ages ranged from 34 to 81 years. Eighteen (90.0%) patients were male. Five patients (25.0%) reported a previous reaction to diclofenac. Reported time from the used dose of diclofenac to onset of the first reaction symptoms ranged from immediately to 5 hours. Diclofenac caused both type I and type II Kounis syndrome, with the presence of various cardiovascular, gastrointestinal, dermatologic, and respiratory signs and symptoms. Most patients experienced hypotension (n = 15 [75.0%]) and chest pain (n = 12 [60.0%]). The most frequently reported finding on electrocardiogram was ST-segment elevations (n = 17 [85.0%]). Coronary angiogram showed normal coronary vessels in 9 patients (45.0%), with some pathologic findings in 8 patients (40.0%).

CONCLUSION

Clinicians should be aware that Kounis syndrome may be an adverse effect of diclofenac. Prompt recognition and withdrawal of the drug, with treatment of both allergic and cardiac symptoms simultaneously, is important.

Cases of allergic coronary syndrome (Kounis syndrome) : what we should know

Kounis syndrome (KS) is an acute coronary syndrome that occurs with allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions associated with mast cell activation, and entails significant morbidity and mortality risks. We present four cases of acute coronary syndrome developing after insect bites, chemotherapy, and coronary stent implantation. Two patients were lost due to anaphylactic shock-related multiorgan failures and sudden cardiac death. Since a wide range of drugs, foods, environmental conditions, and disease states may be associated with KS, all physicians must be aware of the syndrome.

Kounis Syndrome: An Allergic Acute Coronary Syndrome Due to a Bee Sting

Kounis syndrome, also known as allergic acute coronary syndrome, is defined as the occurrence of acute coronary syndrome (ACS) in the setting of an allergic or hypersensitivity reaction. Although Kounis syndrome is not an uncommon disease, many cases go undiagnosed or unrecognized. Patients with systemic allergic reactions associated with evidence of ACS should be suspected of Kounis syndrome because the outcome could be devastating if not treated promptly. The physician must be aware of Kounis syndrome because the treatment modality differs from traditional ACS.

Type III Kounis Syndrome Secondary to Ciprofloxacin-Induced Hypersensitivity

Kounis syndrome (KS) is a rare syndrome characterized by the co-occurrence of acute coronary syndromes in the setting of mast cell and platelet activation in response to hypersensitivity reactions. It can be manifested as coronary vasospasms, acute myocardial infarction, or stent thrombosis triggered by drugs, vaccines, foods, coronary stents, and insect bites. It is a life-threatening condition that needs to be adequately recognized for early diagnosis and appropriate treatment. In this case report, we present a 71-year-old patient with a history of arterial hypertension and non-ST elevation myocardial infarction six months earlier that was treated percutaneously with angioplasty plus stent implantation in the circumflex artery, who subsequently presented to the emergency department due to generalized itching associated with tongue swelling, dyspnea, and chest pain after ingestion of ciprofloxacin for the treatment of a urogenital infection. An electrocardiogram showed ST elevation in II, III, and aVF leads, and positive troponin; thus, a coronary arteriography was performed that showed complete thrombotic stent occlusion in the circumflex artery. Consequently, diagnosis of type 4b inferolateral acute myocardial infarction secondary to ciprofloxacin-triggered type III Kounis syndrome was made. The aim of this report is to understand the relationship between the allergic reaction to ciprofloxacin and the acute coronary syndrome, and to create awareness of the importance of early diagnosis and treatment of this potentially fatal syndrome.

Acute coronary syndrome due to plaque erosion likely triggered by insect bites: a case series of Kounis syndrome

Background

Kounis syndrome is the concurrence of acute coronary syndrome (ACS), including coronary spasm, acute myocardial infarction, and stent thrombosis due to an allergic and/or anaphylactoid insult.

Case summary

We present two cases of Kounis syndrome likely triggered by insect bites, with plaque erosion demonstrated using optical coherence tomography (OCT). Three common findings were derived from this case series. First, the patients developed a rash after an insect bite followed by ACS. Second, immunoglobulin E levels were increased. Finally, OCT identified the aetiology of ACS in this case series as erosion of the culprit lesions.

Discussion

Kounis syndrome, which is ACS following allergic reactions due to insect bites, is a rare complication. Kounis syndrome is probably not uncommon, but underdiagnosed. It is important for physicians to consider the treatment of Kounis syndrome in the complex course of ACS associated with allergic reactions. Furthermore, patients with a history of Kounis syndrome should avoid antigen exposure during secondary prophylaxis. In some cases, it may take several days from antigen exposure to the onset of ACS. Considering Kounis syndrome is beneficial for early diagnosis and appropriate treatment.

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.

Coronary vasospasm: A narrative review

Coronary artery vasospasm (CAVS) plays an important role in acute chest pain syndrome caused by transient and partial or complete occlusion of the coronary arteries. Pathophysiology of the disease remains incompletely understood, with autonomic and endothelial dysfunction thought to play an important role. Due to the dynamic nature of the disease, its exact prevalence is not entirely clear but is found to be more prevalent in East Asian and female population. Cigarette smoking remains a prominent risk factor, although CAVS does not follow traditional coronary artery disease risk factors. Many triggers continue to be identified, with recent findings identifying chemotherapeutics, allergens, and inflammatory mediators as playing some role in the exacerbation of CAVS. Provocative testing with direct visualization is currently the gold-standard for diagnosis, but non-invasive tests, including the use of biomarkers, are being increasingly studied to aid in the diagnosis. Treatment of the CAVS is an area of active research. Apart from risk factor modification, calcium channel blockers are currently the first line treatment, with nitrates playing an important adjunct role. High-risk patients with life-threatening complications should be considered for implantable cardioverter defibrillator (ICD), although timing criteria for escalated therapy require further investigation. The role of pharmaceuticals targeting oxidative stress remains incompletely understood.

Catheter-induced anaphylaxis and determination of the causative catheter in a patient undergoing neuroendovascular surgery: a case report

BACKGROUND

Anaphylaxis caused by a catheter itself used for endovascular surgery is rare, and a method for detection of a causative catheter has not been established. We report a case of catheter-induced anaphylaxis in which the causative catheter was successfully detected.

CASE PRESENTATION

A 47-year-old male underwent neuroendovascular surgery. During surgery, blood pressure suddenly dropped and the level of tryptase indicated the occurrence of anaphylaxis. There were 24 candidate agents for the cause of anaphylaxis including 8 catheters. We performed the basophil activation test by directly mixing the catheter with blood. One catheter coated with a hyaluronic acid product showed a positive reaction, and we confirmed the result by a modified skin test using an elution solution of the catheter. Later, we successfully completed the neuroendovascular surgery without the catheter.

CONCLUSIONS

The methods used in this case can be useful for the detection of the causative agent in catheter-induced anaphylaxis.

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.

Kounis Syndrome Induced by Anisodamine: A Case Report

Kounis syndrome is a rare type of acute coronary syndrome caused by coronary spasm with or without atherosclerotic plaque erosion or rupture due to inflammatory factors released by allergic reactions. Due to a lack of awareness, Kounis syndrome is often underdiagnosed. Here, we for the first time report a case of Kounis syndrome induced by anisodamine. A 48-year-old woman presented with upper abdominal pain and vomiting after eating. She was diagnosed with gastrointestinal spasm and intramuscularly injected with 10 mg anisodamine. The patient subsequently developed chest pain and hypotension with erythematous rash. A systemic allergic reaction was diagnosed. Saline solution, promethazine and dexamethasone were administered immediately. A 12-lead electrocardiogram indicated ST-segment elevation in II, III and aVF leads. Emergent coronary angiography was recommended. According to a preoperative electrocardiogram, the ST-segment elevation in the II, III and aVF leads had disappeared. Coronary angiograph revealed no significant coronary stenosis. The patient was diagnosed with Kounis syndrome induced by anisodamine, showing acute ST-segment elevation myocardial infarction due to allergic coronary vasospasm. During the 9-month follow-up, the patient did not receive further anisodamine injections and remained free of chest pain. In conclusion, it is essential for clinicians to be aware of Kounis syndrome because of the wide range of triggers and its potentially fatal evolution if not identified in time.

Type I Kounis Syndrome after Protracted Anaphylaxis and Myocardial Bridge-Brief Literature Review and Case Report

The term allergic angina, introduced for the first time by Nicholas Kounis in 1991, initially referred to the coexistence of acute coronary syndromes with allergy or hypersensitivity. At present, it is believed that Kounis syndrome is a particular case of systemic disease, with multiorgan arterial involvement generated during immediate hypersensitivity reactions. Myocardial bridging (MB), a condition that can induce coronary artery spasm, has long been regarded as a benign condition. Since both pathologies are associated with arterial spasm, Kounis syndrome and MB are considered to be confounding pathologies for acute coronary syndromes, and their association is quite a rare finding. To date, there are no precise data on the epidemiology, and the population affected by Kounis syndrome seems to be highly heterogeneous. Since this is a rare disease, even less is known about possible different phenotypes, including MB overlap. We report a case of type I variant Kounis syndrome associated with MB with no evidence of coronary artery disease, occurring as late presentation, following a severe systemic reaction (anaphylaxis) induced by a Hymenoptera sting. At present, only two other cases of type I and one case of type II Kounis syndrome occurring in patients with myocardial bridging have been described.

[Prinzmetal angina. Questions of pathogenesis, clinic, diagnosis and treatment]

Current problems of Prinzmetal angina (vasospastic angina, variant angina) considers in this review. Attention is drawn to early diagnosis, which should be comprehensive, taking into account possible atypical courses and the development of complications. The important role of electrocardiographic monitoring (including using implantable recorders) is highlighted. It is emphasized that patients with cardiac arrhythmias, syncope are at high risk of developing sudden cardiac death. In this category of patients, it is recommended to timely determine the indications for implantation of a cardioverter - defibrillator. Authors consider the prospects of using new methods of treatment of angina pectoris.

Kounis syndrome secondary to gadolinium contrast agent

Cases of coronary artery spasm secondary to contrast agent use are rarely reported. Herein, we report the case of a 53-year-old woman who developed chest pain, dyspnea, and bradycardia and quickly become unresponsive after magnetic resonance imaging of the brain. A heart monitor showed ST elevation, and an electrocardiogram showed ST elevations in leads II, III, aVF, V3, and V4 and ST segment depression in lead I. Urgent left heart catheterization revealed no evidence of obstructive coronary artery disease or pulmonary embolism. A few days later, she was discharged from the hospital with no symptoms. A type I variant of Kounis syndrome was diagnosed.