Kounis syndrome: a new twist on an old disease

Type I Kounis Syndrome: Allergic Myocardial Infarction Triggered by Ciprofloxacin

Kounis syndrome (KS), known as allergic myocardial infarction (MI), is an uncommon but potentially life-threatening disease characterized by acute coronary artery disease (CAD) in the setting of allergic reactions. KS is most frequently triggered by medication, and ciprofloxacin-induced KS-I is rarely reported. Here, we present a case of KS-I triggered by ciprofloxacin in a young female with no prior CAD. A 35-year-old female presented with sudden onset chest pain, diaphoresis, and lightheadedness, accompanied by itching, confusion, and collapse, shortly after taking oral ciprofloxacin. Her electrocardiogram showed inferior wall MI with elevated cardiac troponin levels. Urgent coronary angiography was unremarkable. Her condition improved after sublingual nitroglycerine, methylprednisolone, and intramuscular injection of epinephrine. This case highlights the importance of recognizing drug-induced allergic reactions as a potential cause of acute coronary events, particularly in young patients without traditional risk factors.

Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

Influence of Preoperative COVID-19 Vaccination on Outcomes After Coronary Artery Bypass Grafting-A Propensity Score-Matched Analysis

BACKGROUND

Reports of intravascular thrombosis and cardiac complications have raised concerns about the safety of COVID-19 vaccinations, particularly in patients with high cardiovascular risk. Herein, we aimed to analyze the impact of preoperative COVID-19 vaccination on outcomes after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

Among 520 patients who underwent isolated CABG from 2020 to 2022, 481 patients (mean±SD age: 67±11 years, 86 women) whose COVID-19 vaccination status could be confirmed were included. A total of 249 patients who had not received any COVID-19 vaccine before CABG (never vaccinated group) and 214 patients who had completed primary vaccination (fully vaccinated group) were subjected to 1:1 propensity score matching, and 156 pairs of patients were matched. There was no significant difference in early mortality between the 2 groups after matching. After matching, overall survival (P=0.930) and major adverse cardiovascular and cerebrovascular event-free survival (P=0.636) did not differ between the 2 groups. One-year graft patency also did not differ significantly between the 2 groups; all patent grafts in 85/104 patients (82%) and 62/73 patients (85%) in the never vaccinated and fully vaccinated groups, respectively (P=0.685). Subgroup analysis showed equivalent overall and major adverse cardiovascular and cerebrovascular event-free survival among AstraZeneca and Pfizer vaccine recipients and between those with ≤30 days versus >30 days from vaccination to CABG.

CONCLUSIONS

Despite the very high cardiovascular risk for patients undergoing CABG, COVID-19 vaccination did not affect major outcomes after CABG. Therefore, there is no reason for patients with coronary artery disease requiring CABG to avoid preoperative COVID-19 vaccination.

Geographic variation in the clinical features of Mohave rattlesnake (Crotalus scutulatus) envenomations reported to the North American Snakebite Registry

The geographic variation of Mohave rattlesnake (Crotalus scutulatus) venom is well established. We reviewed all the Mohave rattlesnake bites reported to the Toxicology Investigators Consortium's North American Snakebite Registry between January 1, 2015 and 12/31/2021. Data reviewed for this study included details regarding the snake encounter, patient demographics, signs and symptoms, treatment, and outcomes. Our objective was to describe the epidemiology, clinical manifestations, and management of Mohave rattlesnake envenomations using prospective data from two geographically distinct sites. There were 20 subjects, including eight nonpregnant females. Ages ranged from seven to 75 years, median age 48. Nine of the bites were managed in Arizona and 11 in California. In Arizona, all envenomated patients had local swelling. None had neurological toxicity. In California, swelling was present in nine patients. Neurological effects were observed in five subjects. Four Arizona patients and one California patient had hypotension requiring treatment. Each site had one patient with thrombocytopenia. An Arizona patient who sustained a bite to the face was intubated. Rhabdomyolysis occurred in two California patients. All envenomated patients received antivenom. Mohave rattlesnakes have the potential to cause significant local and/or systemic toxicity. Neurotoxicity was not observed in envenomations from Mohave rattlesnakes that presumably lack Mohave toxin, but hypotension and gastrointestinal signs were more common than in bites from snakes believed to possess Mohave toxin. Neurological toxicity was limited to paresthesias and fasciculations. Significant skeletal or respiratory muscle weakness was not observed in our study population.

Cardiac Complications and COVID-19: A Review of Life-threatening Co-morbidities

The novel 2019 coronavirus disease (COVID-19) was first reported in the last days of December 2019 in Wuhan, China. The presence of certain co-morbidities, including cardiovascular diseases (CVDs), are the basis for worse outcomes in patients with COVID-19. Relevant English-language literature was searched and retrieved from the Google Scholar search engine and PubMed database up to 2023 using COVID-19, SARS-CoV-2, Heart failure, Myocardial infarction, and Arrhythmia and Cardiac complication as keywords. Increased hemodynamic load, ischemia-related dysfunction, ventricular remodeling, excessive neurohumoral stimulation, abnormal myocyte calcium cycling, and excessive or insufficient extracellular matrix proliferation are associated with heart failure (HF) in COVID-19 patients. Inflammatory reaction due to the excessive release of inflammatory cytokines, leads to myocardial infarction (MI) in these patients. The virus can induce heart arrhythmia through cardiac complications, hypoxia, decreased heart hemodynamics, and remarkable inflammatory markers. Moreover, studies have linked cardiac complications in COVID-19 with poor outcomes, extended hospitalization time, and increased mortality rate. Patients with COVID-19 and CVDs are at higher mortality risk and they should be given high priority when receiving the treatment and intensive care during hospitalization.

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.

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.

Acute myocardial infarction and myocarditis following COVID-19 vaccination

Emerging reports raise concerns on the potential association between the COVID-19 vaccines and cardiac manifestations. We sought to evaluate cardiac complications associated with COVID-19 vaccination in a pooled analysis from our institution's cohort study and systematic review. Consecutive patients admitted to a tertiary hospital in Singapore between 1 January 2021 and 31 March 2021, with the onset of cardiac manifestations within 14 days following COVID-19 vaccination, were studied. Furthermore, a systematic review was performed, with PubMed, Embase, Research Square, MedRxiv and LitCovid databases accessed from inception up to 29 June 2021. Relevant manuscripts reporting individual patient data on cardiac complications following COVID-19 vaccination were included. Thirty patients were included in the study cohort, with 29 diagnosed with acute myocardial infarction (AMI) and 1 with myocarditis. Five patients developed heart failure, two had cardiogenic shock, three intubated, and one had cardiovascular-related mortality. In the systematic review, 16 studies were included with 41 myocarditis and 6 AMI cases. In the pooled analysis of the study cohort and the systematic review, 35 patients had AMI and 42 had myocarditis. Majority were men, and myocarditis patients were younger than AMI patients. Myocarditis patients tended to present 72 h postvaccination, while AMI patients were older and typically presented 24 h postvaccination. Majority with AMI or myocarditis developed symptoms after the first and second vaccination dose, respectively. This pooled analysis of patients presenting with cardiac manifestations following COVID-19 vaccination highlights the differences between myocarditis and AMI presentations in temporal association with the vaccination.

Cardiovascular Complications in Coronavirus Disease 2019-Pathogenesis and Management

The coronavirus disease 2019 (COVID-19) pandemic has caused a devastating impact on morbidity and mortality around the world. Severe acute respiratory syndrome-coronavirus-2 has a characteristic tropism for the cardiovascular system by entering the host cells and binding to angiotensin-converting enzyme 2 receptors, which are expressed in different cells, particularly endothelial cells. This endothelial injury is linked by a direct intracellular viral invasion leading to inflammation, microthrombosis, and angiogenesis. COVID-19 has been associated with acute myocarditis, cardiac arrhythmias, new onset or worsening heart failure, ischemic heart disease, stroke, and thromboembolic disease. This review summarizes key relevant literature regarding the epidemiology, diagnosis, treatment, and preventive measures related to cardiovascular complications in the setting of COVID-19.

Cardiovascular complications of COVID-19 vaccines: A review of case-report and case-series studies

BACKGROUND

There are multiple reviews on cardiovascular aspects of COVID-19 disease on cardiovascular system in different population but there is lack of evidence about cardiovascular adverse effects of COVID vaccines.

OBJECTIVES

The purpose of this study was to compare the cardiac complications of COVID19 vaccines, based on vaccine type (mRNA, vector-based, and inactivated vaccines).

METHODS

A systematic search was performed covering PubMed for English case-reports and case-series studies, and finally 100 studies were included.

RESULTS

Myocarditis (with overall rate around 1.62%) was shown to be the most common post-COVID19 immunization cardiac event. More than 90% of post-COVID19 vaccination myocarditis occurred after receiving mRNA vaccines (Moderna & Pfizer-BioNTech), but the report of this event was less in the case of vector-based vaccinations and/or inactivated vaccines. Myocarditis was reported more commonly in men and following the second dose of the immunization. Takotsubo cardiomyopathy (TTC) was reported after mRNA (more commonly) and vector-based vaccinations, with no case report after inactivated vaccines. When mRNA and vector-based vaccinations were used instead of inactivated vaccines, a greater frequency of vaccine-induced thrombotic thrombocytopenia (VITT) and pulmonary emboli (PE) was reported. Myocardial infarction/cardiac arrest was recorded in those beyond the age of 75 years.

CONCLUSION

The personal and public health benefits of COVID-19 vaccination much outweigh the minor cardiac risks. Reporting bias, regarding more available mRNA vaccines in developed countries, may conflict these results.

Angina and Arrhythmia Symptoms Following Multiple Bee Stings: Kounis Syndrome

Kounis syndrome (KS) is an acute coronary syndrome including coronary spasm, acute myocardial infarction, and stent thrombosis preceded by an anaphylactic, anaphylactoid, allergic, or hypersensitivity injury. In this case presentation, we discussed Type I and Type II KS. Case 1 was a 72-y-old man who presented to the emergency department with allergic symptoms and chest pain that developed after multiple bee stings. Electrocardiography showed ST depression in the lateral leads. Case 2 was a 42-y-old woman who presented to the emergency department with complaints of chest pain, dizziness, and presyncope that developed after multiple bee stings. Mobitz Type II Block with right bundle branch block was observed in 42 beats·min-1 in the electrocardiography. Both patients were first treated for allergic reaction. Although early percutaneous coronary intervention was performed for graft thrombosis in Case 1, a permanent pacemaker was inserted in Case 2. The patients were discharged without any complications. Increasing physician awareness towards the existence of KS can prevent fatal outcomes with early diagnosis and treatment.

Myocardial infarction following COVID-19 vaccine administration; a systematic review

Introduction

Covid-19 vaccines have been assessed in randomized trials, which are designed to establish efficacy and safety, but are insufficient in power to detect rare adverse outcomes. Among the adverse cardiac events associated with mRNA COVID-19 vaccines are inflammations (e.g., pericarditis or myocarditis), thrombosis, and ischemia.

Objective

This systematic review aims to evaluate the reported cases of myocardial infarction (MI) after COVID-19 vaccinations.

Method

Web of Science, MEDLINE on OVID, PubMed, and Google Scholar were searched for English-language papers published until March 25, 2022.

Results

This study included 15 papers (10 case reports and 5 case series). In total, 20 individuals were included who had received COVID-19 vaccines and experienced MI. Males (55%) reported more adverse occurrences than females (45%) across the majority of event categories. The mean time from the administration of the vaccine to the onset of symptoms was 2 days (0–10 days). The AstraZeneca vaccine was responsible for more than half of the reported events. In the majority of cases, the event developed after receiving the first dose of vaccination.

Conclusion

MI related to COVID19 vaccination is a rare, but serious and life-threatening condition. Chest discomfort should be regarded as a warning sign, particularly in people who have been administered a dose of the vaccine within the previous two days.

Plaque rupture and neovascularisation detected with optical coherence tomography in a case of Kounis syndrome

Kounis syndrome is an allergic acute coronary syndrome (ACS) characterised by coronary artery spasm, plaque erosion/rupture or stent thrombosis caused by mast cell and other interacting cell activation. Although intracoronary imaging modalities can detect those ACS mechanisms, Kounis syndrome due to plaque rupture has rarely been reported using intracoronary imaging. We present the case of a woman in her 70s who developed Kounis syndrome as a result of plaque rupture detected with optical coherence tomography (OCT). She had non-ST-segment elevation ACS as a result of anaphylaxis to cefazolin. Coronary angiography revealed severe stenosis in the left anterior descending artery; angiographically undetectable plaque rupture was detected using OCT. OCT also revealed intraplaque neovascularisation, suggesting that the culprit plaque had been vulnerable. OCT can aid in understanding the underlying mechanisms of Kounis syndrome.

Anaphylaxis and allergic reactions to COVID‐19 vaccines: A narrative review of characteristics and potential obstacles on achieving herd immunity

Background and Aims

Methods

Results

Conclusion

Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management

Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.

Myocardial Infarction Following COVID-19 Vaccine Administration: Post Hoc, Ergo Propter Hoc?

Vaccination against coronavirus disease 2019 (COVID-19) is the safest and most effective strategy for controlling the pandemic. However, some cases of acute cardiac events following vaccine administration have been reported, including myocarditis and myocardial infarction (MI). While post-vaccine myocarditis has been widely discussed, information about post-vaccine MI is scarce and heterogenous, often lacking in histopathological and pathophysiological details. We hereby present five cases (four men, mean age 64 years, range 50–76) of sudden death secondary to MI and tightly temporally related to COVID-19 vaccination. In each case, comprehensive macro- and microscopic pathological analyses were performed, including post-mortem cardiac magnetic resonance, to ascertain the cause of death. To investigate the pathophysiological determinants of MI, toxicological and tryptase analyses were performed, yielding negative results, while the absence of anti-platelet factor 4 antibodies ruled out vaccine-induced thrombotic thrombocytopenia. Finally, genetic testing disclosed that all subjects were carriers of at least one pro-thrombotic mutation. Although the presented cases do not allow us to establish any causative relation, they should foster further research to investigate the possible link between COVID-19 vaccination, pro-thrombotic genotypes, and acute cardiovascular events.

Analysis of Clinical Features of Non-steroidal Anti-inflammatory Drugs Induced Kounis Syndrome

Background

Current knowledge of Kounis syndrome induced by non-steroidal anti-inflammatory drugs (NSAIDs) is based on case reports. This study aimed to investigate the clinical features of Kounis syndrome.

Methods

Case reports of the NSAIDs-induced Kounis syndrome were analyzed by searching Chinese and English databases from 1 January 1950 to 31 January 2022.

Results

The median age of the 45 included patients (28 women) was 51 years (20–80 years). NSAIDs that were the most frequently involved were diclofenac (26.7%, 12/45), metamizole (15.6%, 7/45), and aspirin (13.3%, 6/45). Kounis syndrome occurred mainly within 30 min after administration, with a maximum latency of 1 month. Chest pain (75.6%, 34/45), dyspnea (33.3%, 15/45), and allergic reactions (44.4%, 20/45) were the most common clinical manifestations. Thirty patients (66.7%) had an ST-segment elevation on the electrocardiogram. Echocardiogram and coronary angiography showed abnormalities in 21 patients (75%, 21/28) and 15 patients (37.5%, 15/40). Forty-four patients (97.8%) had a good prognosis after treatment with steroids, antihistamines, and vasodilators.

Conclusion

The possibility of Kounis syndrome should be considered in the presence of coronary artery disease symptoms when taking NSAIDs. Kounis syndrome can be life-threatening. It is essential to identify and treat Kounis syndrome correctly.

Acute Myocardial Infarction After COVID-19 Vaccination: A Case Report

Following the coronavirus disease 2019 (COVID-19) pandemic, nations all over the world started vaccination programs against the SARS-CoV2 virus. With the widespread administration of the vaccine across the globe, various cases were reported with thrombotic events after vaccination. Here, we are presenting a case of acute anterior wall myocardial infarction (AWMI) after ChAdOx1 nCoV- 19 corona virus (recombinant) vaccination. A 68-year-old male who was a known case of hypertension, non-smoker on antihypertensive took COVISHIELD vaccination and presented with acute anterior wall myocardial infarction within 12 hours and was taken up for primary angioplasty. On coronary angiography, mid-left anterior descending artery (LAD) was 99% stenosed. Following angiography percutaneous transluminal coronary angioplasty (PTCA), deployment of a drug eluting stent was done. Post-procedure time was uneventful. He was started on intravenous fluids and amiodarone infusion. The patient recovered and was discharged in stable condition. The leading approach to handling COVID-19 pandemic is mass vaccination. In this case, the MI after vaccination might be coincidental. We want to highlight this case as that the complication can occur during the mass vaccination programs and hence adequate precautionary measures like basic life support, EKG monitoring, and emergency ambulance services should be present in all primary and community health centers (PHC and CHC). This will help in avoiding the COVID vaccination hesitancy among the general public.

Acute myocardial infarction following COVID-19 vaccination: a cause or a coincidence?

Background. Acute Myocardial Infarction (AMI) is a fatal condition with a subsequent variety of complications. Recently, COVID-19 vaccine has become an essential precaution to avoid infection. However, it is uncommon for AMI to manifest as a result of the COVID-19 vaccination. Methods. Thirty-two years old man, previously healthy, come to the emergency department with a four-hour history of chest discomfort after Covishield (AstraZeneca) vaccination. He was neither hypertensive, diabetic, or smoker and lacked any other typical risk factors for cardiovascular disease. Results. This case describes an adverse response to the COVID-19 vaccination that has the potential to be life-threatening. He had received his first dose of the Covishield vaccination five days prior. Extensive anterior STEMI was diagnosed post-cardiac arrest. He had primary percutaneous coronary intervention (PCI) to recanalize an occluded proximal LAD. Conclusions. Additional screenings for young individuals should be considered before administering the COVID-19 (AstraZeneca) vaccine as a preventive step if reports of significant adverse events in older adults continue.

Recognizing Kounis Syndrome, the Unusual Possible Culprit of Acute Coronary Syndrome: A Rare Case Report

Kounis syndrome encompasses acute coronary syndrome features associated with severe vasospasm of the coronary artery. It is related to allergic anaphylactic reaction triggered by the release of inflammatory cells and mediators. This entity, however, is often not properly diagnosed. In this report, we aimed to discuss a case of Kounis syndrome mimicking acute coronary syndrome. We presented a 58-year-old man with dyspnea, chest pain, dizziness, and itchiness 30 minutes following sodium diclofenac ingestion. His physical examination was remarkable for shock with hypoxia and features of anaphylactic reaction. An urgent electrocardiogram was obtained, manifesting deep ST-segment depression in anterolateral leads with ST elevation of aVR, which hinted a severe three-vessel disease or left main disease. Allergic acute coronary syndrome was suspected. Thus, the patient was managed with fluid resuscitation, epinephrine, and corticosteroid injection along with acute coronary syndrome treatment algorithm with a favorable clinical response. One-hour serial ECG showed complete resolution of ST depression with aVR normalization. This pointed to possible acute coronary spasm. No further coronary intervention was performed, the patient was discharged after 2 days in good condition and planned for further cardiac evaluation during follow-up. Kounis syndrome is an intriguing process caused by the presence of two disease entities that must be treated simultaneously. The difficulty in treating this condition stems from the fact that treating one of both entities may aggravate the other. Thus, a comprehensive approach and health education are strongly advised to ensure that this condition does not reoccur in the future.

Clinical Cardiovascular Adverse Events Reported Post-COVID-19 Vaccination: Are They a Real Risk?

Given the urgent need to control the spread of the novel COVID-19 virus, 13 vaccines have been approved for emergency use before completing all 3 phases of the clinical trials. Thereby a careful monitor of the adverse effects postvaccination is essential. We searched through PubMed and other reporting systems like VAERS for the reported cardiovascular adverse events post-COVID-19 vaccination. Through our review, we determined that the incidence of all the reported cardiovascular events is very rare. Additionally, the vaccine was initially given to the elderly and high-risk populations in which cardiovascular events such as myocardial infarction and arrhythmias are already more prevalent, while other cardiovascular events such as myocarditis or vaccine-induced thrombotic thrombocytopenia were more common in younger populations. Moreover, a direct causal relationship, if any, between vaccination and adverse events is yet to be fully elucidated. Thus, at this time point, the benefits of vaccination far outweigh the risk.

Deep Vein Thrombosis After a Wild Bee Sting

Allergic reactions from insect bites are mostly observed with bee stings. Bee sting reactions can be classified into 3 main headings: local, systemic, and rare reactions. Vascular thrombosis is considered both in rare and systemic reactions. The wild bee venom induces the secretion of many inflammatory mediators, including histamine, phospholipase A1, and thromboxane, leading to vasoconstriction and thrombosis. Inflammatory cytokines also cause endothelial injury and deterioration of the microcirculation. In the literature, rare reactions have been reported including various central and arterial vascular pathologies such as aortic thrombosis, cerebral infarction, and myocardial infarction; however, there is rare publication concerning peripheral deep vein thrombosis (DVT). Although DVT produces good results with effective and rapid treatment, it can be fatal because of causes such as pulmonary embolism in the absence of timely intervention. Herein, for the first time in the literature, we present a pediatric case of peripheral DVT after a wild bee sting.

Analysis of clinical characteristics of Kounis syndrome induced by contrast media

BACKGROUND

Understanding the relationship between contrast agents and Kounis syndrome (KS) is mainly based on case reports. The purpose of this research is to explore the clinical characteristics of contrast media induced KS.

METHODS

We searched for contrast-induced KS case reports through Chinese and English databases from 1991 to October 31, 2021.

RESULTS

A total of 26 patients (19 men and 7 women,) were included, with a median age of 60 years (range 30-83). The contrast agents that cause KS mainly included gadolinium-based contrast agent (7 cases), iodine-containing contrast media (12 cases). KS mainly occurred within 30 min after administration and mainly manifests as chest pain and allergic reactions. Electrocardiogram (ECG) mainly showed ST elevation. Echocardiography mainly revealed normal. Coronary angiography showed normal, coronary vasospasm, stent thrombosis, occlusion and stenosis. After treatment with steroids, antihistamines and anti-ischemic therapy, 24 patients recovered completely and 2 patients died.

CONCLUSIONS

KS is a rare adverse reaction of contrast media. Radiologists should recognize this rare but serious disease to ensure rapid diagnosis and proper management.

Cardiovascular Complications of SARS-CoV-2 Vaccines: An Overview

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of the deadly disease known as coronavirus disease 2019 (COVID-19) that has reached pandemic proportions. Currently, there is no definitive treatment for COVID-19, although many vaccines have been developed. The World Health Organization has approved the safety and efficacy of the AstraZeneca/Oxford, Johnson and Johnson/Janssen (JnJ), Moderna, Pfizer/BioNTech, Sinopharm, and Sinovac vaccines so far. The approved formulations of AstraZeneca, JnJ, and Gam-COVID-vac (Sputnik V) contain DNA delivered within non-replicating recombinant adenovirus vector-based systems, while the Pfizer and Moderna vaccines utilize mRNA technology and lipid nanoparticle delivery systems. All of these vaccines encode production of the SARS-CoV-2 spike (S) protein, ultimately triggering immunity in the human body. COVID-19 causes several cardiovascular complications, such as arrhythmias, myocarditis, pericarditis, and venous thromboembolism. SARS-CoV-2 vaccines have been associated with rare, but sometimes fatal, cardiovascular side effects, which are the topics of this review. SARS-CoV-2 vaccines in general may cause thromboembolic events, such as cerebral vein thrombosis, and mRNA-based vaccines in particular may cause myocarditis/pericarditis, with the latter more likely to occur in younger adults after the second vaccination dose. Nevertheless, the advantages of these vaccines for ending the pandemic and/or decreasing the mortality rate outweigh any risk for the rare cardiovascular complications.

Hymenoptera heartaches -cardiac manifestation with hymenoptera stings, a retrospective study from a tertiary care hospital in South India

INTRODUCTION

Hymenoptera stings usually have a multitude of presentations from very subtle to life-threatening conditions. Various cardiac manifestations including Kounis syndrome often get missed due to lack of suspicion. The aim of the study was to describe the clinical profile of the cardiac etiologies associated with hymenoptera stings and review literature with focus on diagnosis and treatment strategies.

METHODOLOGY

A retrospective chart analysis was performed including all adult patients who had a hymenoptera sting during a two-year window (October 2018 - October 2020). Of these, patients with cardiac features were enrolled. A structured case record form was used to capture information like basic demography, clinical profile, and outcomes.

RESULTS

Thirteen cases presented with hymenoptera stings of which six cases had cardiac presentation and were considered. The most common presentations were breathlessness and generalised itching with only one patient complaining of chest pain. All patients(with available data) had ECG changes suggestive of ischemia and associated raised troponin levels with 2D echo changes. The diagnoses considered included Kounis syndrome, hypersensitivity myocarditis, and Takotsubo cardiomyopathy. Patients were managed conservatively with one patient undergoing a coronary angiography. All patients were stable at discharge.

CONCLUSION

Cardiac manifestations with hymenoptera stings although rare may complicate diagnosis and treatment.It should be borne in mind during assessment and standardised guidelines should be developed for ED treatment such as the one recommended in this study.

Some Perspectives on Hypersensitivity to Coronary Stents

The development of coronary stents has represented a revolution in the treatment of coronary heart disease. Beyond their many advantages, stents also have their limitations and complications. Allergic reactions to coronary stents are more common than acknowledged. These stented patients are exposed to foreign substances inserted in direct contact with the coronary intima. Hypersensitivity to stent components and drugs prescribed after stent insertion together with any environmental exposure seem to contribute to these adverse reactions. Patients can present to the hospital with a wide range of symptoms and multiple complications, the most important ones being instent restenosis and stent thrombosis. Although not very common (and not always easy to identify), allergic reactions after coronary or peripheral stents should be taken into account. Careful selection of patients (for elective stent implantation) depending on the propensity to allergies, although hard to achieve, represents a key factor in reducing the number of these complications.

Type I Kounis syndrome variant: A case report and literature review

Kounis syndrome defined as the occurrence of acute coronary syndrome in the setting of allergic reaction due to mast cells activation and inflammatory mediators release that induces coronary vasospasm, plaque erosion, or even stent thrombosis. A 25-year-old postpartum female with asthma and recurrent episodes of chest pain was admitted with ST-segment elevation myocardial infarction in the setting of coronary artery spasms. The patient was started on calcium channel blockers and nitrite-based medication with no improvement. She was noted to have eosinophilia and initiation of corticosteroid-based regimen lead to resolution of chest pain episodes and normalization of eosinophilia. Kounis syndrome should be considered in young patients with chest pain. Coronary vasodilators are considered as the first-line of treatment. The use of corticosteroids has been described in the literature in severe or refractory cases.

COVID-19 Disease, Women's Predominant Non-Heparin Vaccine-Induced Thrombotic Thrombocytopenia and Kounis Syndrome: A Passepartout Cytokine Storm Interplay

Coronavirus disease 2019 (COVID-19) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) constitute one of the deadliest pandemics in modern history demonstrating cardiovascular, gastrointestinal, hematologic, mucocutaneous, respiratory, neurological, renal and testicular manifestations and further complications. COVID-19-induced excessive immune response accompanied with uncontrolled release of cytokines culminating in cytokine storm seem to be the common pathogenetic mechanism of these complications. The aim of this narrative review is to elucidate the relation between anaphylaxis associated with profound hypotension or hypoxemia with pro-inflammatory cytokine release. COVID-19 relation with Kounis syndrome and post-COVID-19 vaccination correlation with heparin-induced thrombocytopenia with thrombosis (HITT), especially serious cerebral venous sinus thrombosis, were also reviewed. Methods: A current literature search in PubMed, Embase and Google databases was performed to reveal the pathophysiology, prevalence, clinical manifestation, correlation and treatment of COVID-19, anaphylaxis with profuse hypotension, Kounis acute coronary syndrome and thrombotic events post vaccination. Results: The same key immunological pathophysiology mechanisms and cells seem to underlie COVID-19 cardiovascular complications and the anaphylaxis-associated Kounis syndrome. The myocardial injury in patients with COVID-19 has been attributed to coronary spasm, plaque rupture and microthrombi formation, hypoxic injury or cytokine storm disposing the same pathophysiology with the three clinical variants of Kounis syndrome. COVID-19-interrelated vaccine excipients as polysorbate, polyethelene glycol (PEG) and trometamol constitute potential allergenic substances. Conclusion: Better acknowledgement of the pathophysiological mechanisms, clinical similarities, multiorgan complications of COVID-19 or other viral infections as dengue and human immunodeficiency viruses along with the action of inflammatory cells inducing the Kounis syndrome could identify better immunological approaches for prevention, treatment of the COVID-19 pandemic as well as post-COVID-19 vaccine adverse reactions.

Kounis Syndrome and Multiorgan Failure Following Multiple Wasp Stings

Wasp and bee stings are common in Sri Lanka, and systemic envenomation causes a spectrum of clinical manifestations that includes simple local allergic reaction to life-threatening multiple organ injury or failure. However, wasp toxin-induced acute myocardial infarction is very rare in the literature. Here, we describe a pregnant lady with mass wasp stings who developed toxin-induced acute myocardial infarction with multiorgan injury. The treating physician should anticipate the complications of massive envenomation following multiple wasp stings.

An Autopsy Case of Spontaneous Coronary Artery Dissection With Eosinophilic Coronary Periarteritis and Degeneration of Medial Smooth Muscles

ABSTRACT

A 45-year-old woman with no known medical history died suddenly shortly after complaining of anterior chest discomfort. The autopsy revealed a dissection at the anterior descending branch of the left coronary artery, and eosinophilic adventitial inflammation was observed both in the right coronary artery and in the vicinity of the dissection. Furthermore, there was degeneration of the tunica media in the right coronary artery, and this was thought to be a predissection lesion. In the degenerated area of the tunica media, probable apoptosis of smooth muscle cells was noted, suggesting that the degeneration was not due only to the effect of eosinophilic lytic enzymes. These findings also indicated that eosinophilic infiltration preceded the dissection. Eosinophilic infiltration around the coronary arteries is occasionally observed in cases of sudden death, but although it might be associated with the death, the pathological mechanism is yet to be elucidated. Eosinophilic periarteritis has also been observed around the site of spontaneous coronary artery dissection, although a causal relationship is unproven. The histopathology of this case indicated that the eosinophilic infiltration preceded the dissection. Detailed pathological findings are presented, together with a review of the literature.

Acute Coronary Syndrome and Arrhytmia Induced by SARS-CoV-2 Infection in a Patient with Non-Significant LAD Lesion. A Case Report

Background: Coronavirus disease 2019 (COVID-19) has emerged as a pandemic and public health crisis of an unprecedent effect. Clinical studies reported an association between COVID-19 and cardiovascular disease, whereas COVID-19 itself can induce myocardial injury, arrhythmia, acute coronary syndrome, and venous thromboembolism.

Case summary: A patient diagnosed via screening coronary computed tomography angiography with non-obstructive coronary artery disease was hospitalized with non-ST elevation myocardial infarction and atrial flutter during a severe respiratory infection episode with SARS-CoV-2. After recovery from the infectious episode, fractional flow reserve-guided elective percutaneous coronary intervention with drug-eluting stent was performed.

Conclusions: COVID-19 intercurrence in a cardiovascular patient with nonobstructive coronary artery disease triggered coronary plaque vulnerabilization with subsequent development of an acute coronary syndrome. SARS-CoV-2 proved to be involved via direct viral tissue involvement and concomitant mechanisms derived from systemic illness in the development of a severe supraventricular arrhythmic event.

Allergic Reactions to Current Available COVID-19 Vaccinations: Pathophysiology, Causality, and Therapeutic Considerations

Vaccines constitute the most effective medications in public health as they control and prevent the spread of infectious diseases and reduce mortality. Similar to other medications, allergic reactions can occur during vaccination. While most reactions are neither frequent nor serious, anaphylactic reactions are potentially life-threatening allergic reactions that are encountered rarely, but can cause serious complications. The allergic responses caused by vaccines can stem from activation of mast cells via Fcε receptor-1 type I reaction, mediated by the interaction between immunoglobulin E (IgE) antibodies against a particular vaccine, and occur within minutes or up to four hours. The type IV allergic reactions initiate 48 h after vaccination and demonstrate their peak between 72 and 96 h. Non-IgE-mediated mast cell degranulation via activation of the complement system and via activation of the Mas-related G protein-coupled receptor X2 can also induce allergic reactions. Reactions are more often caused by inert substances, called excipients, which are added to vaccines to improve stability and absorption, increase solubility, influence palatability, or create a distinctive appearance, and not by the active vaccine itself. Polyethylene glycol, also known as macrogol, in the currently available Pfizer-BioNTech and Moderna COVID-19 mRNA vaccines, and polysorbate 80, also known as Tween 80, in AstraZeneca and Johnson & Johnson COVID-19 vaccines, are excipients mostly incriminated for allergic reactions. This review will summarize the current state of knowledge of immediate and delayed allergic reactions in the currently available vaccines against COVID-19, together with the general and specific therapeutic considerations. These considerations include: The incidence of allergic reactions and deaths under investigation with the available vaccines, application of vaccination in patients with mast cell disease, patients who developed an allergy during the first dose, vasovagal symptoms masquerading as allergic reactions, the COVID-19 vaccination in pregnancy, deaths associated with COVID-19 vaccination, and questions arising in managing of this current ordeal. Careful vaccine-safety surveillance over time, in conjunction with the elucidation of mechanisms of adverse events across different COVID-19 vaccine platforms, will contribute to the development of a safe vaccine strategy. Allergists’ expertise in proper diagnosis and treatment of allergic reactions is vital for the screening of high-risk individuals.

Elements of Immunoglobulin E Network Associate with Aortic valve Area in Patients with Acquired Aortic Stenosis

Allergic mechanisms are likely involved in atherosclerosis and its clinical presentations, such as coronary artery disease (CAD). It has been previously reported that CAD severity associates with serum levels of immunoglobulin E (IgE), the molecule that, along with its high-affinity receptor (FcԑRI), plays a central role in allergic reactions. Considering multiple pathophysiological similarities between atherosclerosis and acquired aortic (valve) stenosis (AS), we speculated that allergic pathways could also contribute to the AS mechanisms and grading. To validate this hypothesis, we first checked whether total serum IgE levels associate with echocardiographic markers of AS severity. Having found a positive correlation between serum IgE and aortic valve area (AVA), we further speculated that also total IgE-determining genetic polymorphisms in FCER1A, a locus encoding an allergen-biding FcԑRI subunit, are related to acquired AS severity. Indeed, the major allele of rs2251746 polymorphism, known to associate with higher IgE levels, turned out to correlate with larger AVA, a marker of less severe AS. Our findings surprisingly suggest a protective role of IgE pathways against AS progression. IgE-mediated protective mechanisms in AS require further investigations.

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.

Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called 'Kounis-like' syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.

Epidemiology of rare allergic diseases in children

Allergic diseases have different frequencies. In particular, allergic rhinitis and asthma have high frequencies of about 20% and 10%, respectively. Other allergic diseases have lower frequencies; for example, food allergy has a frequency of 1%-4%. There are also rare allergic diseases, with a prevalence of 5 cases per 10 000 people in the general population, and they are included in Orphanet. However, other extremely rare allergic diseases still need to be properly known in order to be possibly recognized as rare diseases and cataloged in Orphanet.

Kounis syndrome after patent blue dye injection for sentinel lymph node biopsy

BACKGROUND

Kounis syndrome (KS) has been described as an acute coronary syndrome (ACS) associated with an anaphylactic reaction. Several triggers have been identified and the diagnostic and treatment process can be challenging.

CASE

A 58-year-old, female patient diagnosed with breast cancer and no history of allergies had subcutaneous injection of patent blue V dye for sentinel lymph node biopsy (SLNB). Intraoperatively, she developed anaphylactic shock and was transferred to the intensive care unit (ICU). A few hours later, electrocardiographic alterations and elevation of blood troponin were observed. Emergency coronary angiography revealed no occlusive lesions in coronary vessels. Further investigation in the allergy department set the diagnosis of KS.

CONCLUSION

There are just ten cases of perioperative KS in the literature so far and here we present the first one triggered by patent blue V dye for sentinel node biopsy.