Drug induced Kounis syndrome: does oxidative stress play a role?

Cephalosporin triggered Kounis syndrome: Pathophysiological and clinical insights

BACKGROUND

Acute coronary syndrome triggered by hypersensitivity to various natural, chemical, or pharmaceutical allergens is known as Kounis syndrome. Kounis syndrome is classified in three subtypes based on its pathophysiological mechanism and outcome. Among pharmaceuticals, cephalosporins are frequently implicated in allergic illnesses, with ceftriaxone being one of the most frequently reported causes. Based on literature reports and our own experience, we focused on the main clinical features regarding ceftriaxone triggered KS (CTKS).

METHODS

Medical records from all CTKS cases, as published by the end of December 2024, were retrieved and analyzed, including a patient admitted to our hospital after inadvertent twice ceftriaxone administration.

RESULTS

Clinical findings from 10 CTKS patients, mean aged 61 ± 18 (range 24-85) years, 5 males, were studied. Type-I KS (coronary vasospasm) was found in 8 cases (80 %), whereas 2 more patients showed a type-II variant (atheromatous plaque thrombosis), with the right artery as the most involved coronary vessel. Apart from transient hemodynamic instability in 2 patients on admission, everyone was discharged in a good clinical condition.

CONCLUSIONS

CTKS is a rare, but likely underrecognized, clinical condition that may occur regardless of gender, age, history of allergy or preexisting coronary artery disease. The predominant type-I variant indicates a transient coronary asospasm (and/or microcirculatory impairment) as the most likely pathogenic mechanism. Key pathophysiological, clinical, and prognostic aspects are discussed.

Case Report: An unusual case of cardiac anaphylaxis in the maintenance phase of vespula venom immunotherapy

Background

Cardiac involvement in anaphylaxis remains difficult to assess; however, histamine release during an anaphylactic reaction can induce functional and metabolic alterations in the myocardium. Mast cells, identified within myocardial fibers, perivascular tissue, and arterial structures, play a crucial role in systemic and cardiac anaphylaxis through the release of inflammatory mediators, including histamine, platelet-activating factor, cytokines, chemokines, tryptase, chymase, prostaglandins, and leukotrienes. Hymenoptera venom immunotherapy (VIT) is the most effective strategy for preventing systemic reactions in sensitized individuals. Although VIT is generally well tolerated, severe allergic reactions can occur, particularly during the build-up phase, while they are rare in the maintenance phase.

Case report

We present the case of a 57-year-old male with a history of severe systemic reactions (SSR) to Vespula stings who experienced cardiac anaphylaxis during the maintenance phase of VIT. He started VIT with a conventional up-dosing schedule, which was well-tolerated. However, during the third monthly maintenance dose, he developed an anaphylactic syncopal episode with a right bundle branch block (RBBB) on ECG. He was treated promptly with adrenaline, corticosteroids, and antihistamines, and his ECG normalized within 20 days.

Conclusions

This case underscores the potential cardiac involvement in anaphylaxis during VIT maintenance and highlights the need to systematically evaluate cardiovascular manifestations during anaphylaxis episodes to optimize risk assessment and management.

Kounis Syndrome: Review of Clinical Cases

BACKGROUND

Kounis syndrome is defined as a combination of acute coronary syndrome and allergic reactions.

OBJECTIVE

In this review, we aim to describe the etiological, clinical, and diagnostic characteristics of Kounis syndrome.

METHODS

A literature search using PubMed was conducted for the past 32 years using keywords, resulting in the selection of 761 scientific papers. From these, 217 articles describing 235 clinical cases were selected. Patients under 18 years of age or without a confirmed diagnosis were excluded.

RESULTS

Among the 235 patients, type I Kounis syndrome was observed in 49.7%, type II in 27.2%, type III in 5.9%, and a combination of types I and II in 1.0%; in 16.2%, it was not possible to classify the type of Kounis syndrome. The median age was 57 years, and 68.5% of the patients were male. The most common causes were antibiotics (32.3%) and non-steroidal anti-inflammatory drugs (24.3%). The clinical features included chest pain (59.1%), hypotension (74.2%), itching (30.6%), and dyspnea (30.6%). Electrocardiographic monitoring revealed ST-segment elevation in 42.9% and was normal in only 5.5% of patients. Coronary angiography was performed in 80.4% of the patients, revealing unchanged coronary arteries in 50.3% of cases. Сonclusion: Allergic myocardial infarction is a serious complication of drug therapy.

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.

Kounis Syndrome Leading to Cardiac Arrest After Iodinated Contrast Exposure

Immune-mediated coronary spasm, called Kounis syndrome (KS), is not rare but is underdiagnosed. In this report, we present a case of KS induced by iodinated contrast resulting in cardiac arrest, requiring temporary mechanical circulatory support. We show angiographic evidence of KS and outline commonly associated clinical features that may predict KS. (Level of Difficulty: Beginner.).