Allergic Acute Coronary Syndrome-Kounis Syndrome.

Acute coronary syndrome (ACS) in the setting of an allergic/immunologic reaction is known as Kounis syndrome. It is an underdiagnosed and underrecognized disease entity. One must keep a high index of suspicions when managing a patient presenting with cardiac as well as allergic symptoms. There are 3 main variants to the syndrome. Treating the allergic reaction may alleviate the pain; however, ACS guidelines should be followed if cardiac ischemia is present.

Kounis Syndrome: A Sting to the Heart.

A 67-year-old woman experienced pruritus, an urticarial rash, and acute, pressure-like chest pain following an insect sting. Initial electrocardiographic findings were notable for ST-segment elevations in the inferior leads without reciprocal changes, but a follow-up electrocardiogram showed pronounced ST-segment elevations in the inferior leads with reciprocal changes. Her troponin I level peaked at 3,053 pg/mL, and she was transferred to a large academic center for percutaneous coronary intervention. Balloon angioplasty was performed for 95% thrombotic occlusion of the mid-right coronary artery, and a drug-eluting stent was placed. The patient's presentation was consistent with type II Kounis syndrome.

Kounis syndrome caused by bee sting: a case report and literature review.

Kounis syndrome is defined as an acute coronary syndrome (ACS) secondary to allergic or hypersensitivity reactions. It can be further categorised into subtypes such as coronary vasospasms, acute myocardial infarction or stent thrombosis based on the pathogenesis. Kounis syndrome is most likely an underdiagnosed condition in China, given the many triggers reported in the literature. Herein, we report a case of Kounis syndrome, possibly triggered by a bee sting. The patient had late onset of angina symptoms with delayed diagnosis due to unfamiliarity with this condition. In patients with clinical signs of ACS that are superimposed on a hypersensitivity reaction, especially those with pre-existing cardiovascular risk factors, Kounis syndrome should be considered, so that appropriate assessment and treatment can be initiated. Prompt management of both the allergic reaction and the ACS is vital for Kounis syndrome.

Recurrent Coronary Vasospasm: A Case of Kounis Syndrome from Anaphylaxis to Contrast Dye.

Kounis syndrome is characterized by acute coronary syndrome due to coronary vasospasm or thrombosis following exposure to an allergic stimulus. The presentation can be compounded by cardiovascular collapse due to cardiogenic shock from coronary vasospasm and associated vasodilatory shock from anaphylaxis. A high index of suspicion is crucial for prompt initiation of treatment, which focuses on managing the allergic or anaphylactic process. Here we present a case of coronary vasospasm and anaphylactic shock due to contrast dye exposure during percutaneous coronary intervention of an unstable coronary lesion and its associated diagnostic and therapeutic challenges.

Early Use of ECMO for Refractory Kounis Syndrome Concealed by General Anesthesia-A Case Report.

A 46-year-old woman demonstrated refractory Kounis syndrome (KS) after induction of anesthesia. Despite conventional management of anaphylaxis and advanced cardiac life support, her cardiovascular function continued to deteriorate until she had a cardiac arrest, and after extracorporeal membrane oxygenation (ECMO) therapy, electrical cardiac activity reappeared. A large number of patients with KS-"allergic angina syndrome"-has been known to recover well with vasodilators; however, this patient showed antibiotics-induced refractory KS during general anesthesia. Severe bronchospasms with desaturation appeared as initial anaphylactic features; however, these did not respond to conventional treatment for anaphylaxis. Patient's hemodynamic signs eventually worsened, leading to cardiac arrest despite ephedrine administration and chest compressions. During cardiopulmonary cerebral resuscitation, the central line was secured, and epinephrine, atropine, as well as sodium bicarbonate were administered repeatedly; nevertheless, cardiac arrest was sustained. After initiation of veno-arterial ECMO, atrial fibrillation was observed, which was later converted to sinus tachycardia by electrical cardioversions and amiodarone. Coronary angiography was performed before the patient was admitted to the intensive care unit; there were no indications of an impending cardiac arrest. The patient was discharged uneventfully owing to early use of ECMO despite the emergence of KS symptoms that were initially masked by anesthesia but later worsened abruptly.

Kounis syndrome: from an unexpected case in the Emergency Room to a review of the literature.

Kounis syndrome (KS) is a coronary syndrome in the setting of allergic/anaphylactic reactions and can be classified in three variants: vasospastic allergic angina (type I), allergic myocardial infarction (type II) and stent thrombosis (type III). The early diagnosis is of paramount importance for the correct management and the prognosis, being KS a life-threatening emergency condition. KS is not uncommon, but it is frequently unrecognized or undiagnosed in virtue of its broad clinical manifestations. The diagnosis should be based on the combination of cardiovascular and allergic/anaphylactic clinical symptoms and signs, as well as on laboratory, electrocardiographic, echocardiographic, and angiographic evidence. ECG monitoring, cardiac enzymes and troponin are mandatory to confirm or exclude KS in a patient with subclinical or clinical, acute or chronic allergic reactions. Nevertheless, the treatment is a real challenge for the emergency clinicians because guidelines have not been established yet, and the therapy is based on the variant type. We herein report the case of type I KS in a woman with no prior history of allergy, admitted to our emergency department for abdominal pain, nausea and hematochezia. Starting from this case we conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline, using the keywords of "Kounis syndrome", "coronary spams", "cardiac arrest", "sudden death", "allergy", and "anaphylaxis". The main purpose of this review is to remind emergency clinicians to keep a high index of suspicion regarding KS when dealing with patients with allergic reactions or anaphylaxis to promptly identify and correctly manage KS.

Acute coronary syndrome because of a scorpion sting in a patient with chronic coronary syndrome: A case report and review of the literature.

The occurrence of acute coronary syndrome (ACS) following a scorpion sting has been very rarely reported in literature, and most of the cases presented had a normal coronary angiogram. The possible pathogenetic mechanisms include imbalance in blood pressure and coronary spasm caused by a combination of sympathetic excitation with subsequent thrombosis of coronary vessels developed after the release of vasoactive, inflammatory, and thrombogenic substances contained in the scorpion venom. In this report, we present a case of a scorpion sting complicated by ACS, called Kounis syndrome (KS). His coronary angiogram revealed the presence of significant stenosis of the left anterior descending artery. He was treated successfully with percutaneous transluminal coronary angioplasty, antivenom serum, and supportive therapy.

Recurrent Type III Kounis Syndrome: Will Anti-Immunoglobulin E Drug Be Another Option?

Kounis syndrome was recognized as the concurrence of acute cardiovascular events with hypersensitivity reactions. We report a case of Kounis syndrome type III (coronary thrombosis) variant in a 48-year-old man who had experienced recurrent acute myocardial infarctions after scallion-induced hypersensitivity reactions. After appropriate antithrombotic, antihistamine, and reperfusion strategies, the patient was found to have elevated levels of immunoglobulin E and chronic urticaria. Upon administration of omalizumab, there was an improvement of chronic urticaria, a decrease in immunoglobulin E levels, and resolution of the ischemic attacks.

Kounis Syndrome after Angioplasty of the Superficial Femoral Artery with Paclitaxel-Coated Balloon.

Drug-coated balloons are used widely as a form of endovascular treatment for peripheral arterial disease, to improve patency by reducing neointimal hyperplasia and restenosis. We present a rare case of acute coronary syndrome secondary to anaphylaxis after inflation of a paclitaxel-coated balloon used to treat a recurrent superficial femoral artery stenosis.

Kounis syndrome. Apropos of a clinical case. / Síndrome de Kounis. A propósito de um caso clínico.

Kounis syndrome, while an acute coronary syndrome, occurs in the context of a hypersensitivity reaction, allergies, or anaphylaxis and is subdivided into three types: coronary spasm in normal arteries, instability of plaques in atherosclerotic coronary arteries, and thrombosis of coronary stents. Herein, the case of a 73-year-old patient who, after administration of amoxicillin/clavulanic acid, went into cardiorespiratory arrest with evidence of ST-T segment elevation on electrocardiogram is reported. Coronarography revealed no obstructive lesions, and spontaneous resolution of electrocardiographic abnormalities was observed. A review of anamnesis with the family revealed a previous allergy to penicillin. The tryptase dosage was strongly positive. Kounis syndrome type 2 was diagnosed, and the clinical outcome was good.

Síndrome de Kounis. A propósito de um caso clínico / Kounis syndrome. Apropos of a clinical case

RESUMO A síndrome de Kounis, enquanto síndrome coronária aguda, ocorre em um contexto de reação de hipersensibilidade, alergia ou anafilaxia, e subdivide-se em três tipos: o espasmo coronário em artérias normais, a instabilidade de placas em artérias coronárias ateroscleróticas e a trombose de stent coronário. Apresenta-se o caso de uma doente de 73 anos que, após administração de amoxicilina/ácido clavulânico, entra em parada cardiorrespiratória, com evidência de supradesnivelamento do segmento ST-T em eletrocardiograma. Realiza coronariografia com ausência de lesões obstrutivas, verificando-se resolução espontânea das alterações eletrocardiográficas. Revisão da anamnese com a família documenta alergia prévia à penicilina. O doseamento de triptase foi fortemente positivo. Foi admitida provável síndrome de Kounis tipo 2, com boa evolução clínica posterior.

ABSTRACT Kounis syndrome, while an acute coronary syndrome, occurs in the context of a hypersensitivity reaction, allergies, or anaphylaxis and is subdivided into three types: coronary spasm in normal arteries, instability of plaques in atherosclerotic coronary arteries, and thrombosis of coronary stents. Herein, the case of a 73-year-old patient who, after administration of amoxicillin/clavulanic acid, went into cardiorespiratory arrest with evidence of ST-T segment elevation on electrocardiogram is reported. Coronarography revealed no obstructive lesions, and spontaneous resolution of electrocardiographic abnormalities was observed. A review of anamnesis with the family revealed a previous allergy to penicillin. The tryptase dosage was strongly positive. Kounis syndrome type 2 was diagnosed, and the clinical outcome was good.

Vasoespasmo coronario en un niño alérgico al látex: síndrome de Kounis / Coronary vasospasm in a child allergic to latex: Kounis syndrome

El síndrome de Kounis consiste en la aparición simultánea de anafilaxia y síndrome coronario agudo. Se trata de una entidad poco descrita y que puede estar infradiagnosticada en pediatría. Es crucial, por su presentación variable, atípica e inesperada, y por sus posibles complicaciones graves (arritmias ventriculares, infarto de miocardio, muerte súbita), su reconocimiento y tratamiento precoz, dirigido a la revascularización del miocardio y al tratamiento de la reacción anafiláctica concomitante. Se presenta el caso de un varón de 11 años que, tras el contacto con látex, presentó una reacción anafiláctica asociada a vasoespasmo coronario, con recuperación rápida y completa con la administración de adrenalina intramuscular. El estudio cardiológico descartó patología coronaria como causa del evento. El estudio alergológico puso de manifiesto un síndrome de reactividad cruzada látex-frutas (kiwi y piña). Se diagnosticó síndrome de Kounis tipo i desencadenado por látex, y se recomendó evitar posibles factores desencadenantes.

Kounis syndrome consists of the simultaneous occurrence of anaphylaxis and acute coronary syndrome. It is a rare entity that may be underdiagnosed in paediatrics. The clinical presentation is variable, atypical and usually unexpected, and it carries possible serious complications such as ventricular arrhythmias, myocardial infarction and sudden death. Therefore, an early diagnosis and treatment for myocardial revascularization and the anaphylactic reaction are crucial. We report the case of an 11-year-old male who, after contact with latex, presented an anaphylactic reaction associated with coronary vasospasm, with rapid and complete recovery after administration of intramuscular adrenaline. The cardiological study ruled out coronary pathology as the cause of the event. The allergy study revealed a latex-fruit (kiwi and pineapple) cross-reactivity syndrome. The patient was diagnosed with type I Kounis syndrome triggered by latex, recommending the avoidance of possible triggers.

[Kounis syndrome, the allergic acute coronary syndrome]. / Kounis-syndroom.

BACKGROUND: The occurrence of acute ischaemia or myocardial infarction in a patient experiencing an allergic reaction is known as allergic acute coronary syndrome or Kounis syndrome. CASE DESCRIPTION: A 63-year-old male had a postoperative anaphylactic reaction to an intravenous dose of diclofenac. Myocardial ischaemia occurred during treatment of the anaphylaxis, caused by spasm of the right coronary artery followed by occlusion of the left anterior descending artery (the ramus interventricularis anterior). Despite percutaneous coronary intervention, he suffered an infarct of the anterior myocardium, resulting in reduced left ventricular function. CONCLUSION: In patients with Kounis syndrome therapy should focus on both the allergy and the acute coronary syndrome. Early recognition and intervention have a great effect on prognosis.

Systemic Mastocytosis, Kounis Syndrome and Coronary Intervention: Case Report and Systematic Review.

A 72-year-old male reported a long-standing history of unexplained syncope. Stress echocardiography demonstrated inducible anterior hypokinesis, and he proceeded to percutaneous coronary intervention for an 80% stenosis of the left anterior descending artery. Thirty minutes post-procedure, he experienced a pulseless electrical activity (PEA) cardiac arrest. Urgent repeat angiography demonstrated profound coronary artery spasm consistent with Kounis syndrome. Three days later, a second PEA arrest occurred. Systemic mastocytosis was ultimately diagnosed as the cause of his recurrent syncopal episodes and cardiac arrests. Our patient was discharged 56days after his cardiac arrest on appropriate immunotherapy, and has made an excellent event-free recovery. Systemic mastocytosis is the pathological accumulation of mast cells in organs, and it may cause life-threatening syncope and cardiac arrests. It is estimated to affect up to 1 in 10,000 people, however is often underdiagnosed. No previous reviews have examined cardiac manifestations of systemic mastocytosis. We undertook a structured systematic review of cardiac presentations of systemic mastocytosis in adults, screening 619 publications. Twenty-three cases met inclusion criteria; our review suggests that short-term mortality is high (22%), and patients with cardiac presentations are predominantly male (83%). Unexplained cardiac arrest (26%) may be the first presentation of this haematological disorder. From our review of the literature, we have also derived suggested management approaches for cardiologists encountering or suspecting systemic mastocytosis in a variety of clinical scenarios.

Kounis Syndrome During Anesthesia: Presentation of Indolent Systemic Mastocytosis: A Case Report.

Mastocytosis comprises a heterogeneous group of disorders characterized by mast cell accumulation and proliferation in distinct organs. Kounis syndrome is defined as the concurrence of acute coronary syndromes with mast cell activation in a setting of allergic or hypersensitivity reactions. This is the first reported case of an intraoperative Kounis syndrome as the onset of an indolent systemic mastocytosis probably triggered by succinylated gelatin infusion during general anesthesia. The presentation of this case is intended to contribute to the knowledge of mastocytosis and Kounis syndrome at the time of diagnostic workup during intraoperative anaphylaxis or myocardial ischemia.

Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome.

Kounis syndrome (KS) is a hypersensitivity coronary disorder induced by exposure to drugs, food, environmental and other triggers. Vasospastic allergic angina, allergic myocardial infarction (MI) and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three main variants of this syndrome. We reviewed 175 patients who fulfilled the definition of one of the three types of KS. The epidemiology, diagnostic findings, management and complications were reviewed in this article.