Kounis syndrome: acute inferior myocardial infarction with atroventricular node block due to ceftriaxone: a first reported case

Analysis of Clinical Features of Kounis Syndrome Induced by Cephalosporin

Background

Cephalosporins are an increasingly encountered cause of Kounis syndrome. The present study examined the clinical features of cephalosporin-induced Kounis syndrome and provided references for diagnosis, prevention, treatment, and prognosis.

Methods

We collected cephalosporin-induced Kounis syndrome case reports by searching Chinese and English databases from the establishment of the database to October 31, 2021.

Results

Twenty-five patients (17 males and eight females) were included, with a median age of 61 years (range 33–92). Cephalosporins were administered via oral, intravenous and intramuscular routes. All reactions occurred within 30 min, except in two patients. Fourteen patients experienced chest pain, 19 experienced hypotension, 16 had cutaneous reactions, 10 had respiratory symptoms, and seven had gastrointestinal symptoms. Thirteen patients had elevated troponin levels, and eight patients had elevated serum tryptase levels. The electrocardiogram showed ST-segment elevation in 13 patients, depression in four patients, and elevation and depression in six patients. Coronary angiography showed normal results in 12 patients and abnormal results in 13 patients. The skin prick test was positive for cephalosporin in three patients. Twenty-four of the 25 patients recovered after being given anti-allergic and acute coronary syndrome treatment, and there was one death.

Conclusions

Kounis syndrome is a serious adverse reaction to cephalosporin. Clinicians should consider Kounis syndrome in every patient receiving cephalosporin and presenting with acute chest pain or anaphylactic symptoms.

Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation, in the absence of chest pain

This is a review of the underlying causes of the association of ST segment elevation and gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and anorexia, in patients who do not have chest pain. The review was based on anecdotal reports in Googlescholar and Pubmed using the search terms, abdominal pain, nausea, vomiting, anorexia, ST elevation, myocardial infarction, and Takotsubo cardiomyopathy. Those patients who did not have acute myocardial infarction as the cause of the association of ST segment elevation and gastrointestinal symptoms were compared with counterparts with similar symptoms who had well authenticated acute myocardial infarction or Takotsubo cardiomyopathy as the underlying cause of ST segment elevation. The underlying causes of gastrointestinal symptoms which could be associated with ST segment elevation in the absence of either acute myocardial infarction or Takotsubo cardiomyopathy comprised pneumonia, pulmonary embolism, perforated gastric ulcer, intestinal obstruction, acute appendicitis, acute pancreatitis, acute cholecystitis, pheochromocytoma, bacterial meningitis, diabetic keto acidosis, and cannabis abuse. However, each of those disorders could also coexist either with acute myocardial infarction or with Takotsubo cardiomyopathy. The coexistence of ST segment elevation and gastrointestinal symptoms(without chest pain) was also documented in patients with esophageal perforation, mesenteric ischaemia, aortic dissection, Kounis syndrome, and in electrolyte disorders. In the context of presentation with gastroenterological symptoms but without concurrent chest pain, echocardiography appeared to be useful in distinguishing between "pseudo" myocardial infarction characterised by ST segment elevation in the absence of cardiac disease vs ST segment elevation attributable either to acute myocardial infarction or to Takotsubo cardiomyopathy.

Vancomycin-induced coronary artery spasm: a case of Kounis syndrome

Kounis syndrome defined as the appearance of acute coronary syndrome in the context of an allergic reaction is a relatively rare phenomenon. There are three variants of this syndrome in which the patient presents with symptoms of an acute chest. Herein, we describe a case of an 83-year-old woman who demonstrated type I variant of Kounis syndrome in response to vancomycin administration. After initialisation of vancomycin, she became unresponsive and an ECG demonstrated ST changes consistent with inferior-lateral myocardial infarction. Once allergic stimulus was removed, ECG normalised. Differential diagnosis includes, myocardial infarctions, angina as well as intravascular stent thrombosis, which must all be ruled out. The patient was monitored and discharged soon thereafter.