Penicillin allergy in cancer patients manifesting as Kounis syndrome

Exploring Variations in Etiology and Clinical Presentations of Kounis Syndrome Across Pediatric and Adult Populations: A Comprehensive Review

Kounis syndrome (KS), recognized as a rare yet significant form of acute coronary syndrome precipitated by allergy-mediated mechanisms, poses diagnostic challenges due to its varied clinical presentations and under-recognition. Despite its relevance across diverse populations, comprehensive insights into age-specific characteristics and management remain limited. The analysis of 420 studies yielded a total of 466 case reports of Kounis syndrome, categorized into pediatric (n = 31) and adult (n = 435) populations. After rigorous screening, 330 adult and 20 pediatric case reports were included for further analysis. Triggering factors were identified, with drugs (other) being the most prevalent in both groups. The breakdown of triggering factors, such as drugs (antibiotics), bee/wasp stings, and contrast media, was elucidated. Variations in presenting symptoms, diagnostic investigations, and treatment modalities between pediatric and adult populations were observed. Notably, all pediatric cases were diagnosed with subtype I Kounis syndrome and demonstrated favorable outcomes without any reported fatalities, whereas adult cases exhibited a broader range of Kounis subtypes. Mortality was recorded solely in adult case reports, with no fatalities reported among pediatric cases. These findings underscore the importance of understanding the nuances in the clinical presentation and management of Kounis syndrome across different age groups.

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.

Kounis syndrome is likely culprit of coronary vasospasm induced by capecitabine

Capecitabine administration has been associated with various allergic reactions including acneiform skin rash, linchenoid photosensitive eruption, exudative non healing scalp, skin reactions, pyogenic granuloma, subacute cutaneous systemic lupus erythematosus, exudative hyponychia dermatitis, and hand–foot syndrome. A patient who developed ventricular fibrillation following capecitabine-induced coronary vasospasm and necessitating cardioverter-defibrillator implantation was published recently in J Oncol Pharm Practice. The authors attributed this reaction to capecitabine cardiotoxicity, but capecitabine hypersensitivity is closely associated with Kounis syndrome. Tests and measures which will help to confirm, prevent and treat cardiac hypersensitivity to antineoplastic agents are recommended.

Current understanding of Kounis syndrome

Inflammatory mediators, adhesion molecules of neutrophils and monocytes, have been shown to be increased in the plasma of patients presenting with acute coronary syndromes. Anaphylaxis is a systemic, immediate hypersensitivity reaction caused by rapid IgE-mediated release of mediators from mast cells and basophils. Kounis syndrome is the coincidental occurrence of these two distinct conditions accompanied by clinical and laboratory findings of angina pectoris caused by inflammatory mediators released during an allergic insult. Allergic angina can progress to acute myocardial infarction, which is termed 'allergic myocardial infarction'. There are several causes reported to be capable of inducing Kounis syndrome. These include a number of conditions, several drugs, foods and insect stings, among others. In this article, the clinical aspects, diagnosis, pathogenesis, incidence and epidemiology, related conditions and therapeutic management of this important syndrome are discussed.

Drug-eluting stent thrombosis: the Kounis hypersensitivity-associated acute coronary syndrome revisited

The advent of drug-eluting stents (DES) has revolutionized the field of interventional cardiology. Their dramatic and persistent restenotic and target lesion revascularization advantages are unquestioned. However, concerns over the rare but potentially catastrophic risk of stent thrombosis (ST) have tempered universal acceptance of these devices. Although the precise mechanism of DES ST is undoubtedly multifactorial and as yet not fully elucidated, delayed or incomplete endothelial healing clearly plays a pivotal role. Detailed histopathological data have implicated a contributory allergic or hypersensitivity component, as verified by the Food and Drug Administration's Manufacturer and User Device Experience Center and the Research on Adverse Drug/device events And Reports (RADAR) project. These findings thus suggest a potential connection with the Kounis syndrome, the concurrence of acute coronary events with allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions. Potential culprits responsible for this phenomenon include: arachidonic acid metabolites such as leukotrienes and thromboxane, proteolytic enzymes such as chymase and tryptase, histamine, cytokines, and chemokines. Additionally, inflammatory cells such as macrophages, T-lymphocytes, and mast cells are probably also contributory. Autopsy-confirmed infiltrates of various inflammatory cells including lymphocytes, plasma cells, macrophages, and eosinophils have been reported in all 3 vascular wall layers and are reminiscent of those associated with the Kounis syndrome. Although the concurrence of acute coronary syndromes with hypersensitivity reactions has been long established, the specific association with DES ST remains unproven. Potential incorporation of hypersensitivity suppressive agents might represent a promising paradigm shift from efficacy to safety in future DES designs.

Kounis Syndrome secondary to cefuroxime axetil use in an asthmatic patient

A sixty-one year old female with a past history of asthma was admitted to the emergency department because of vertigo, nausea, vomiting, chest pain and generalized erythema after taking an oral dose of cefuroxime axetil. Electrocardiography showed ST segment elevation in inferior leads. After coronary angiography, type 2 variant of Kounis Syndrome is diagnosed. We present first drug induced Kounis Syndrome in an asthmatic patient with severe anaphylactic shock. The present report also shows that atopic people expressing an amplified mast cell degranulation may have more serious hemodynamic decompensation during hypersensitivity reactions.

Coronary spasm and hypersensitivity to amoxicillin: Kounis or not Kounis syndrome?

Several reports have suggested that the onset of allergic phenomena in predisposed subjects may trigger an angina episode, and this association has been described as Kounis syndrome. However, no previous reports have convincingly demonstrated a causal relationship between allergic reactions and acute coronary syndrome, and other possible mechanisms have not been excluded as causes of angina onset. We present a patient with chronic metabolic acidosis because of ureteroileourethrostomy and history of hypersensivity to beta-lactamic agents. He suffered three episodes of documented vasospastic angina, two of them related to amoxicillin administration; however, worsening of metabolic acidosis was found in all three episodes. This report shows that although allergic phenomena could play a role triggering this kind of acute coronary syndrome, other uncommon underlying mechanisms should be considered before the diagnosis of Kounis syndrome is established.

Kounis syndrome secondary to amoxicillin/clavulanic acid use in a child

The concurrence of acute coronary syndromes with allergic or hypersensitivity as well as with anaphylactic or anaphylactoid reactions is increasingly encountered in clinical practice and there are several reports associating mast cell activation with acute cardiovascular events in adults. It was first described by Kounis as "allergic angina syndrome" progressing to "allergic myocardial infarction". The main mechanism proposed is the vasospasm of coronary arteries. This condition has not been described in childhood. We present a 13-year-old boy, admitted to our hospital with thoracic pain, 30 min after the ingestion of an oral dose of 500 mg of amoxicillin/clavulanic acid.

Coronary Stents, Hypersensitivity Reactions, and the Kounis Syndrome

The use of drug-eluting stents (DES) for the treatment of coronary stenosis has increased sharply and now accounts for more than 75% of all coronary stents utilized. However, concern has been increasing that DES could be associated with stent thrombosis, paradoxical coronary vasoconstriction, and hypersensitivity reactions. Components of currently used DES have been reported to induce, either separately or synergistically, hypersensitivity reactions and possibly lead to cardiac events. DES-activated intracoronary mast cells could release histamine, arachidonic acid metabolites, proteolytic enzymes, as well as a variety of cytokines, chemokines, and platelet-activating factor (PAF) leading to local inflammation and thrombosis. These events may be more common than suspected because it is hard to document them, unless they become systemic, in which case they manifest themselves as the "Kounis syndrome," characterized by the concurrence of acute coronary events with hypersensitivity reactions. Recognition of this problem may lead to better vigilance, as well as new DES with mast cell blocking molecules that may also be disease modifying.

The Pathophysiology of Shock in Anaphylaxis

The balance of evidence from human observations and animal studies suggests that the main pathophysiologic features of anaphylactic shock are a profound reduction in venous tone and fluid extravasation causing reduced venous return (mixed hypovolemic-distributive shock) and depressed myocardial function. Aggressive fluid resuscitation is required to ameliorate hypovolemic-distributive shock, and an intravenous infusion of epinephrine will increase vascular tone, myocardial contractility, and cardiac output in most cases. Where these measures fail, pathophysiologic considerations and anecdotal evidence support the consideration of selective vasoconstrictors as the next step in treatment.

Kounis syndrome secondary to amoxicillin/clavulanic acid use

Myocardial injury and acute coronary syndrome have been rarely associated with amoxicillin/clavulanic acid intake. The responsible pathogenetic mechanism is described by an amplified mast cell degranulation inducing coronary artery spasm and/or acute myocardial infarction in susceptible individuals which is called Kounis syndrome. We report here a case of Kounis syndrome presented with acute coronary syndrome due to amoxicillin/clavulanic acid use. All other etiologies, including ischemic reinfarction were appropriately ruled out.

Kounis syndrome associated with hypersensitivity to hymenoptera stings

Hymenoptera stings can induce acute coronary syndromes by different pathogenetic mechanisms including direct action of the venom constituents on the coronary endothelium or allergic reaction with mediators acting on the coronary vasculature. Two patients were stung by wasps and honeybees and developed Kounis syndrome as a consequence of allergic reaction. Kounis syndrome is the concurrence of acute coronary syndromes with mast cell activation induced by allergic or hypersensitivity and anaphylactic of anaphylactoid reactions. It is caused via inflammatory mediators released through mast cell activation. The patients had pre-existing coronary artery disease (type II variant of Kounis syndrome) and the allergic reaction induced by hymenoptera stings seems to have triggered inflammatory mediator release. The pathophysiology and clinical implications of this association are discussed.

Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm?

Inflammatory mediators including histamine, neutral proteases, arachidonic acid products, platelet activating factor and a variety of cytokines and chemokines are increased in blood or urine in both allergic episodes and acute coronary syndromes. The release of mediators during allergic insults has been incriminated to induce coronary artery spasm and/or atheromatous plaque erosion or rupture. A common pathway between allergic and non-allergic coronary syndromes seems to exist. Today, there is evidence that mast cells not only enter the culprit region before plaque erosion or rupture but they release their contents before an actual coronary episode. Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation including allergic or hypersensitivity and anaphylactic or anaphylactoid insults. It is caused by inflammatory mediators released through mast cell activation. Kounis syndrome, as consequence, of the above pathophysiologic association is regarded as nature's own experiment and magnificent natural paradigm showing novel way in an effort to prevent acute coronary syndromes. Drugs and natural molecules which stabilize mast cell membrane and monoclonal antibodies that protect mast cell surface could emerge as novel therapeutic modalities capable to prevent acute coronary and cerebrovascular events.