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Tekin G, Tekin YK. Takotsubo or Kounis syndrome; Diagnosis is made retrospectively. Am J Emerg Med 2024; 78:219-220. [PMID: 38341318 DOI: 10.1016/j.ajem.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Affiliation(s)
- Gülaçan Tekin
- University of Sivas Cumhuriyet, Faculty of Medicine, Department of Cardiology, Sivas, Turkey
| | - Yusuf Kenan Tekin
- University of Sivas Cumhuriyet, Faculty of Medicine, Department of Emergency Medicine, Sivas, Turkey.
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2
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Ali S, Athar M, Rahman R, Rehman F. Ceftriaxone-induced Kounis syndrome: A case report and review of the literature. Rev Esp Anestesiol Reanim (Engl Ed) 2024; 71:129-133. [PMID: 37683977 DOI: 10.1016/j.redare.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/22/2023] [Indexed: 09/10/2023]
Abstract
Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.
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Affiliation(s)
- S Ali
- Department of Anaesthesiology and Critical Care, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - M Athar
- Department of Anaesthesiology and Critical Care, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.
| | - R Rahman
- Department of Anaesthesiology and Critical Care, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - F Rehman
- Department of Anaesthesiology and Critical Care, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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3
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Dikici Ü, Özdemir Ö. Kounis Syndrome Induced by Lidocaine. J Investig Allergol Clin Immunol 2023; 33:505-506. [PMID: 38095498 DOI: 10.18176/jiaci.0936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Affiliation(s)
- Ü Dikici
- Division of Allergy and Immunology, Department of Pediatrics, Research and Training Hospital of Sakarya University Medical Faculty, Adapazarı, Sakarya, Türkiye
| | - Ö Özdemir
- Division of Allergy and Immunology, Department of Pediatrics, Research and Training Hospital of Sakarya University Medical Faculty, Adapazarı, Sakarya, Türkiye
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4
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Abstract
Summary Background. Kounis syndrome (KS) is defined as a rare cause of an acute coronary syndrome associated with systemic allergic reactions. To establish the prevalence of KS among the patients with diagnosis of anaphylaxis, we described clinical features, cardiological and allergological outcomes of patients evaluated in our allergy outpatient clinic. Methods. A retrospective study was carried out in the Allergy Unit of Novara hospital, from January 2008 to March 2020. Skin tests and in vitro tests were performed with suspected etiological agents. Results. We found 9 adults with KS (2%) out of 444 subjects who had experienced anaphylactic reactions (4/9 to Hymenoptera stings, 5/9 to drugs). Conclusions. The present study highlights the importance of suspicion of KS that appears not so uncommon in patients with anaphylaxis. KS seems to be a rare disease because unrecognized in diagnosis of anaphylaxis.
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Affiliation(s)
- G Zisa
- Allergy Unit, Department of Internal Medicine, Hospital Maggiore della Carità, Novara, Italy
| | - A Panero
- Department of Medicine, Hospital of Biella, Biella, Italy
| | - A Re
- Department of Medicine, Hospital Maggiore della Carità, Novara, Italy
| | - M G Mennuni
- Division of Cardiology, Hospital Maggiore della Carità, Novara, Italy
| | - G Patti
- Division of Cardiology, Hospital Maggiore della Carità, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - M Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of Internal Medicine, Hospital Maggiore della Carità, Novara, Italy
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Lin WJ, Zhang YQ, Fei Z, Liu DD, Zhou XH. Kounis syndrome caused by bee sting: a case report and literature review. Cardiovasc J Afr 2023; 34:256-259. [PMID: 36044199 DOI: 10.5830/cvja-2022-042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 08/03/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Wen-Juan Lin
- Department of Cardiology, The First Affiliated Hospital of Zhejiang University, Hangzhou, China.
| | - Yue-Qing Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Zhen Fei
- Department of Cardiology, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Dan-Dan Liu
- Department of Cardiology, Changxing Hospital of Traditional Chinese Medicine, Huzhou, China
| | - Xing-Hang Zhou
- Department of Internal Medicine, Hengdian Hospital, Dongyang, China
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6
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Hong AD, Fleissner ZJ, Campos-Cuellar C, Gonzalez-Estrada A, Mao SA, Doris Wang R, Pai SL. Kounis Syndrome, an Unrecognized Presentation of Perioperative Anaphylaxis in a Transplant Candidate. Prog Transplant 2023; 33:270-271. [PMID: 37533329 DOI: 10.1177/15269248231191485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Andrew D Hong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Zachary J Fleissner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Shennen A Mao
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - R Doris Wang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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7
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Ichinomiya T, Sekino M, Toba M, Yokoyama A, Iwasaki N, Kasai Y, Araki H, Yano R, Matsumoto S, Kurobe M, Sasaki R, Hara T. Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report. Medicine (Baltimore) 2023; 102:e34535. [PMID: 37565887 PMCID: PMC10419590 DOI: 10.1097/md.0000000000034535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
RATIONALE Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome. PATIENT CONCERNS A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach. DIAGNOSES On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome. INTERVENTIONS Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min. OUTCOMES After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae. LESSONS If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.
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Affiliation(s)
- Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Megumi Toba
- Department of Anesthesia, Sasebo City General Hospital, Nagasaki, Japan
| | - Akihiro Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naoya Iwasaki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yusuke Kasai
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Araki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Rintaro Yano
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sojiro Matsumoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaya Kurobe
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryu Sasaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Affiliation(s)
- C Allam
- From the Faculty of Medicine, Saint-Joseph University, Damascus road, Beirut, 175208, Lebanon
- Department of Cardiology, Hôtel-Dieu de France Hospital, Alfred Naccache Blvd, Beirut, 166830, Lebanon
- Address correspondence to C. Allam, MD, Department of Cardiology, Hôtel-Dieu de France Hospital, Alfred Naccache Blvd, Beirut, Lebanon.Tel: +961 71 157280.
| | - M Saouma
- From the Faculty of Medicine, Saint-Joseph University, Damascus road, Beirut, 175208, Lebanon
- Department of Cardiology, Hôtel-Dieu de France Hospital, Alfred Naccache Blvd, Beirut, 166830, Lebanon
| | - Roy Chlawit
- From the Faculty of Medicine, Saint-Joseph University, Damascus road, Beirut, 175208, Lebanon
- Department of Cardiology, Hôtel-Dieu de France Hospital, Alfred Naccache Blvd, Beirut, 166830, Lebanon
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9
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Arnal Campos CP. Nursing care for patients with Kounis syndrome. Enferm Clin (Engl Ed) 2022; 32:203-209. [PMID: 35562010 DOI: 10.1016/j.enfcle.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/08/2021] [Indexed: 06/15/2023]
Abstract
Kounis syndrome (KS) is defined as the occurrence of a coronary event secondary to a severe allergic reaction. This syndrome is described as poorly known, underdiagnosed and with a low prevalence whose aetiology is difficult to know due to the large number of causative agents. The objective is to create an individualized care plan for a patient with Kounis syndrome. The nursing assessment was performed on admission using Virginia Henderson's need theory. A care plan was developed following the NANDA-NOC-NIC taxonomy. After the planning and execution phase, the proposed activities were evaluated, thus verifying that the objectives had been achieved.
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Ramos Jovani M, Vázquez S, Regueiro Cueva A, Farrero M. Metamizol-induced vasospasm: Kounis syndrome - an often overlooked diagnosis. Emergencias 2022; 34:155-156. [PMID: 35275472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Marc Ramos Jovani
- Servicio de Cardiología, Hospital Clínic, Universidad de Barcelona, España
| | - Sara Vázquez
- Servicio de Cardiología, Hospital Clínic, Universidad de Barcelona, España
| | | | - Marta Farrero
- Servicio de Cardiología, Hospital Clínic, Universidad de Barcelona, España
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11
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Bonnet R, Mahmoudi A, Carrel G, Cook S. Iodinated contrast media induced Kounis syndrome during coronary angiogram: a life-threatening clinical dilemma. BMJ Case Rep 2022; 15:e245047. [PMID: 35354572 PMCID: PMC8968983 DOI: 10.1136/bcr-2021-245047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/04/2022] Open
Abstract
Kounis syndrome (KS) is a well-documented hypersensitivity vasospastic reaction induced by a variety of triggers. Clinical presentation ranges from non-specific symptoms such as dizziness and nausea to myocardial infarction. Many cases of KS were reported after the use of iodinated contrast media, mainly during radiological procedures. This report describes the case of a 46-year-old man developing coronary vasospasm and anaphylactic shock at the end of percutaneous coronary intervention. Occurrence of such pathology while performing coronary angiogram is a tricky situation for the invasive cardiologist. It requires recognising a rare syndrome and interrupting the procedure to avoid extra use of contrast media even in presence of severe coronary lesions due to vasospasm. Every interventionalist should be aware of such a presentation to recognise and react promptly when facing a potentially life-threatening clinical dilemma.
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Affiliation(s)
- Romain Bonnet
- Internal Medicine Department, HFR Fribourg Hopital Cantonal, Villars-Sur-Glane, Fribourg, Switzerland
| | - Allal Mahmoudi
- Cardiology Department, HFR Fribourg Hopital Cantonal, Villars-Sur-Glâne, Fribourg, Switzerland
| | - Guillaume Carrel
- Intensive Care Department, HFR Fribourg Hopital Cantonal, Villars-Sur-Glâne, Fribourg, Switzerland
| | - Stephane Cook
- Cardiology Department, HFR Fribourg Hopital Cantonal, Villars-Sur-Glâne, Fribourg, Switzerland
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Affiliation(s)
| | - V Wiwanitkit
- Department of Community Medicine, Dr DY Patil University, Pune, India
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13
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Yamashita T, Oguma Y, Kounis NG. Kounis Syndrome: Kill Two Birds With One Stone. J Invasive Cardiol 2021; 33:E920-E921. [PMID: 34735359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A 59-year-old man with a 95% stenosis in his diagonal branch and no stenosis in the right coronary artery (RCA) or left circumflex artery was scheduled for PCI. After exhibiting symptoms consistent with type I Kounis syndrome (KS), nitroglycerin was administered. While giving him intravenous epinephrine to maintain his hemodynamics, the ST level recovered, and he became fully conscious. When he complained of chest pain, a new ST elevation was noticed in the lateral leads, with ST levels in the inferior leads turning into depression. Repeat angiography demonstrated neither spasm nor occlusion in the RCA, while the diagonal branch was completely occluded at the proximal portion, which was considered to be responsible for ST elevation in the lateral leads. This is the first reported case that combined 2 variants of KS in a single event.
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Affiliation(s)
- Takehiro Yamashita
- Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, 2-1-16-1, Miyanosawa, Nishiku, Sapporo, Hokkaido 063-0052, Japan.
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Lorenzoni G, Merella P, Casu G. Allergic Myocardial Infarction: An Unusual Cause of Stent Thrombosis. J Invasive Cardiol 2021; 33:E758-E759. [PMID: 34473080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Our case confirms that an allergic insult can cause an acute myocardial infarction in a stable coronary disease setting. It also suggests that type 3 Kounis syndrome must be suspected in cases of apparently unexplained "very late" stent thrombosis.
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Affiliation(s)
- Giovanni Lorenzoni
- Unita' Operativa Complessa di Cardiologia, Ospedale San Francesco, Via Mannironi, Nuoro, 08100 Italy.
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Amino M, Fukushima T, Uehata A, Nishikawa C, Morita S, Nakagawa Y, Murakami T, Yoshioka K, Ikari Y. Should beta-blockers be continued as a treatment for myocardial infarction in the case of Kounis syndrome? Ann Noninvasive Electrocardiol 2021; 26:e12837. [PMID: 33783917 PMCID: PMC8293598 DOI: 10.1111/anec.12837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 12/20/2022] Open
Abstract
A 71-year-old male patient reported to our hospital with anaphylactic shock, and the following two issues were focused in this case. First, he was resistant to adrenaline because of taking beta-blocker, and shock was repeated until glucagon administration was initiated. Second, he developed acute coronary syndrome. Two mechanisms contributing to Kounis syndrome were differentiated: 1) adrenaline induced coronary spasm and platelet activation or 2) a mismatch between oxygen supply and demand due to an allergic reaction. Beta-blocker therapy was discontinued because his cardiac function was preserved. Secondary preventive beta-blockers in recovering myocardial infarction with severe anaphylaxis history should be carefully considered.
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Affiliation(s)
- Mari Amino
- Department of CardiologyTokai UniversityIseharaJapan
- Department of Emergency Care MedicineTokai UniversityIseharaJapan
| | | | - Atsushi Uehata
- Department of Emergency Care MedicineTokai UniversityIseharaJapan
| | - Chiemi Nishikawa
- Department of Emergency Care MedicineTokai UniversityIseharaJapan
| | - Seiji Morita
- Department of Emergency Care MedicineTokai UniversityIseharaJapan
| | | | | | | | - Yuji Ikari
- Department of CardiologyTokai UniversityIseharaJapan
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Castro Jiménez A, Olivencia Peña L, García García R, Florido López F, Torres Sánchez E, Molina Navarro E. Therapeutic management in Kounis syndrome: allergen immunotherapy adjuvant to antithrombotic therapy. Emergencias 2021; 33:247-248. [PMID: 33978348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
| | | | | | | | - Elena Torres Sánchez
- Medicina Urgencias y Emergencias, Hospital Virgen de las Nieves, Granada, España
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Portero-Portaz JJ, Córdoba-Soriano JG, Gallego-Page JC. Type III Kounis syndrome after administration of an echocardiography contrast agent. Eur Heart J Acute Cardiovasc Care 2020; 9:NP1-NP2. [PMID: 27325844 DOI: 10.1177/2048872616655943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A dobutamine stress echocardiogram was performed in a 72-year-old woman to assess an intermediate lesion in the left anterior descending artery. After administration of the echocardiography contrast agent, she presented with an anaphylactic reaction and in that context a subacute thrombosis of a drug-eluting stent implanted 15 days before. This is a case of the so-called type III Kounis syndrome.
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Watanabe S, Sakai C, Hori M, Kawasaki T. Insight into the Time Course of Type III Kounis Syndrome: A Case Report. J Emerg Med 2020; 59:e65-e68. [PMID: 32536494 DOI: 10.1016/j.jemermed.2020.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/16/2020] [Accepted: 04/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Kounis syndrome is a rare condition that is characterized by the coexistence of acute coronary syndrome and allergic reactions; however, its time course remains unclear. We report a case of anaphylactic shock with subsequent development of ST-segment elevation myocardial infarction. CASE REPORT A 47-year-old man with food allergies presented to the emergency department of our hospital with breathing difficulties after eating bread. He had a history of angina and underwent stent implantation 3 years earlier. On examination, he was lethargic, disoriented, and in shock. He had a rash on his face and anterior chest wall, as well as severe itching and sweating. Anaphylaxis was diagnosed and, 3 min after presentation, 0.5 mg epinephrine was injected intramuscularly into the right thigh. Electrocardiography, which was recorded 2 min after the administration of epinephrine, was normal; however, chest pain developed suddenly 18 min later. Repeat electrocardiography showed ST-segment elevations, and emergency coronary angiography revealed total occlusion of the left anterior descending coronary artery (i.e., the previous stenting site). Recanalization of the left anterior descending coronary artery was achieved after repeated thrombus aspiration with difficulty, followed by stent implantation inside of the stent under the support of intra-aortic balloon pumping. The clinical course was uneventful. He was discharged and advised to avoid eating wheat and carry an epinephrine self-injection kit for anaphylaxis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The present case highlights the importance of recognizing Kounis syndrome in the management of anaphylactic shock because treatment may be difficult, particularly in patients with type III Kounis syndrome.
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Affiliation(s)
- Seiru Watanabe
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
| | - Chieko Sakai
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
| | - Masatoshi Hori
- Department of Emergency, Matsushita Memorial Hospital, Osaka, Japan
| | - Tatsuya Kawasaki
- Department of Cardiology, Matsushita Memorial Hospital, Osaka, Japan
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Frountzas M, Karathanasis P, Vrakopoulou GZ, Theodoropoulos C, Zografos CG, Schizas D, Zografos GC, Michalopoulos NV. Kounis syndrome after patent blue dye injection for sentinel lymph node biopsy. Breast Cancer 2020; 27:1191-1197. [PMID: 32601801 DOI: 10.1007/s12282-020-01129-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/22/2020] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Maximos Frountzas
- 1st Department of Propaedeutic Surgery, Medical School, "Hippocratio" General Hospital, University of Athens, 114 Vas. Sophias Av, 11527, Athens, Greece.
| | - Panagiotis Karathanasis
- 1st Department of Propaedeutic Surgery, Medical School, "Hippocratio" General Hospital, University of Athens, 114 Vas. Sophias Av, 11527, Athens, Greece
| | - Gavriella Zoi Vrakopoulou
- 1st Department of Propaedeutic Surgery, Medical School, "Hippocratio" General Hospital, University of Athens, 114 Vas. Sophias Av, 11527, Athens, Greece
| | - Charalampos Theodoropoulos
- 1st Department of Propaedeutic Surgery, Medical School, "Hippocratio" General Hospital, University of Athens, 114 Vas. Sophias Av, 11527, Athens, Greece
| | - Constantinos G Zografos
- 1st Department of Surgery, Medical School, University of Athens, "Laiko" General Hospital, 17 Agiou Thoma St, 11527, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, Medical School, University of Athens, "Laiko" General Hospital, 17 Agiou Thoma St, 11527, Athens, Greece
| | - George C Zografos
- 1st Department of Propaedeutic Surgery, Medical School, "Hippocratio" General Hospital, University of Athens, 114 Vas. Sophias Av, 11527, Athens, Greece
| | - Nikolaos V Michalopoulos
- 1st Department of Propaedeutic Surgery, Medical School, "Hippocratio" General Hospital, University of Athens, 114 Vas. Sophias Av, 11527, Athens, Greece
- 4th Dept. of Surgery, Medical School, "Attikon" University Hospital, University of Athens, 1 Rimini St, 12462, Chaidari, Greece
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20
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Duarte P, Costa J, Serena C, Almeida C, Gouveia S, Lourenço C, Costa H, Paiva C. Kounis syndrome. Apropos of a clinical case. Rev Bras Ter Intensiva 2020; 32:149-152. [PMID: 32401974 PMCID: PMC7206957 DOI: 10.5935/0103-507x.20200021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 08/05/2019] [Indexed: 11/20/2022] Open
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.
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Affiliation(s)
- Pedro Duarte
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
- Corresponding author: Pedro Duarte, Hospital do Divino Espírito Santo de Ponta Delgada, Avenida D. Manuel I, 9500-463 - Ponta Delgada, Portugal. E-mail:
| | - Joana Costa
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
| | - Cátia Serena
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
| | - Carla Almeida
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
| | - Sandra Gouveia
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
| | - César Lourenço
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
| | - Humberto Costa
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
| | - Clara Paiva
- Hospital do Divino Espírito Santo de Ponta Delgada - Ponta Delgada, Portugal
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21
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Kounis N, Koniari I, Tsigkas G, Davlouros P. Rectosigmoid ischemia and cerebral coma following gadolinium-induced anaphylaxis: A new manifestation of Kounis syndrome presented as devastating complication. Ann Ital Chir 2020; 91:442-444. [PMID: 33833137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Gadolinium-based contrast mediums are the most commonly used agents in magnetic resonance imaging for both angiography, and brain tumor enhancement due to their association with the degradation of the blood-brain barrier. When oxidation is removed from gadolinium medium and gadolinium salts, a silvery-white metal anions remain that are able to induce allergic reactions and anaphylaxis. Whereas such reactions are not common, other reactions including nephrogenic systemic fibrosis and acute kidney injury due to primary excretion of gadolinium from the kidneys and various cardiac arrhythmias including QTc electrocardiographic prolongation are occasionally encountered 1,2. Despite that gadolinium-based contrast mediums are characterized as benign agents, in some occasions they can lead to life threatening conditions and Kounis syndrome 2-5. The concurrence of acute coronary syndromes such as coronary spasm, acute myocardial infarction, and stent thrombosis, with conditions associated with mast-cell and platelet activation involving other interrelated and interacting inflammatory cells, such as macrophages and Tlymphocytes in the setting of allergic or hypersensitivity and anaphylactic or anaphylactoid insults constitute the Kounis syndrome 6. This syndrome is caused by inflammatory mediators such as histamine, neutral proteases, arachidonic acid products, platelet-activating factor, and a variety of cytokines and chemokines released during the degranulation process of these inflammatory cells. Platelets bearing specific fragment crystallizable region receptors are also involved in the activation cascade 7. All these inflammatory cells participate in an inflammatory cycle and activate each other via multidirectional signals.
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22
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Ng BH, Tan HX, Vijayasingham S. Kounis syndrome following solenopsis (fire ant) bite. Med J Malaysia 2019; 74:344-346. [PMID: 31424048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Anaphylaxis is rarely associated with the vasospastic acute coronary syndrome with or without the presence of underlying coronary artery disease. We report here a case of Kounis syndrome in a man with no known cardiovascular risk developed acute ST-elevation myocardial infarction complicated with complete heart block following Solenopsis (fire ant) bite.
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Affiliation(s)
- B H Ng
- University Kebangsaan Malaysia Medical Center, Department of Medicine, Kuala Lumpur, Malaysia.
| | - H X Tan
- Melaka General Hospital, Department of Medicine, Melaka, Malaysia
| | - S Vijayasingham
- Melaka General Hospital, Department of Medicine, Melaka, Malaysia
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23
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Mengoni A, Carluccio E, Aimi A, Giannandrea D, Broccatelli A, Ambrosio G, Cavallini C. [Hypokinetic cardiac arrest and hypereosinophilia: a case of Kounis or Churg-Strauss syndrome?]. G Ital Cardiol (Rome) 2018; 19:655-657. [PMID: 30425395 DOI: 10.1714/3012.30113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Ischemic heart disease can be caused by multiple factors. However, epidemiological studies have evidenced an association between hypereosinophilia and acute coronary syndrome, most frequently observed in the Kounis and Churg-Strauss syndromes. We here report the case of a 37-year-old man, who was admitted to our hospital for acute coronary syndrome, complicated by hypokinetic cardiac arrest with severe hypereosinophilia.
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Affiliation(s)
- Anna Mengoni
- Cardiologia e Fisiopatologia Cardiovascolare, Ospedale S. Maria della Misericordia, Perugia
| | - Erberto Carluccio
- Cardiologia e Fisiopatologia Cardiovascolare, Ospedale S. Maria della Misericordia, Perugia
| | - Alessandro Aimi
- U.O. Neurologia, USL Umbria 1 Centro Ictus - Ospedale di Gubbio e Gualdo Tadino (PG)
| | | | | | - Giuseppe Ambrosio
- Cardiologia e Fisiopatologia Cardiovascolare, Ospedale S. Maria della Misericordia, Perugia
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Mota I, Gaspar Â, Morais-Almeida M. Perioperative Anaphylaxis Including Kounis Syndrome due to Selective Cefazolin Allergy. Int Arch Allergy Immunol 2018; 177:269-273. [PMID: 29913447 DOI: 10.1159/000490182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/14/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Perioperative use of cefazolin has been associated with severe allergic reactions, and patients are usually labelled as allergic to penicillin afterwards. The aim of our study was to describe a group of patients with immediate reactions to cefazolin, with proven selective hypersensitivity reactions. METHODS Systematic review of all patients followed at our drug centre with cefazolin-related reactions, between January 2012 and December 2016. All patients were investigated according to the European Network for Drug Allergy (ENDA) recommendations through skin testing (major and minor penicillin determinants, penicillin, amoxicillin, cefazolin, cefuroxime and ceftriaxone) and oral challenges tests. RESULTS We included 7 patients (median age 40 years) with perioperative anaphylactic reactions immediately after cefazolin injection, 4 with hypotension and 1 with Kounis syndrome (KS) type I. The presence of a selective IgE-mediated hypersensitivity through positive skin tests to cefazoline has been proven in all patients. Two patients experienced systemic reactions during skin testing. All patients were successfully challenged with amoxicillin, and they tolerated cefuroxime. CONCLUSIONS Cefazolin can be responsible for immediate severe allergic reactions in perioperative setting, including KS. Allergological workup is essential for an accurate diagnosis and to explore cross-reactivity between cefazolin and other beta-lactams. Our experience confirmed that patients with IgE-mediated hypersensitivity reactions to cefazolin can tolerate other beta-lactams. This selective pattern of clinical reactivity may be explained by its particular chemical structure, whose R1 side-chain is different from other beta-lactams.
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Adachi H, Ihara M, Nojima Y, Kurimoto T, Nanto S. Kounis syndrome caused by anaphylaxis without skin manifestations after cefazolin administration. J Allergy Clin Immunol Pract 2018; 7:317-319. [PMID: 29902529 DOI: 10.1016/j.jaip.2018.05.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Hidenori Adachi
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan.
| | - Madoka Ihara
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Yuhei Nojima
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Tetsuya Kurimoto
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Sinsuke Nanto
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
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Bianco M, Lario C, Destefanis P, Luciano A, Cerrato E, Gravinese C, Cirillo S, Pozzi R. [Intravenous epinephrine for anaphylaxis: Kounis or takotsubo syndrome?]. G Ital Cardiol (Rome) 2018; 19:242-245. [PMID: 29912239 DOI: 10.1714/2898.29219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The presence of an acute coronary syndrome in patients with anaphylaxis is a challenging diagnostic conundrum for the cardiologist. Both Kounis syndrome and takotsubo syndrome must be taken into account. We present here the case of a 46-year-old woman suffering from ventricular fibrillation after adrenaline infusion for an anaphylactic reaction. The case report shows the important role of a clear diagnostic work-up and the role of cardiac magnetic resonance in this clinical scenario to reach the final diagnosis of reverse takotsubo cardiomyopathy.
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Affiliation(s)
- Matteo Bianco
- Divisione di Cardiologia, A.O.U. San Luigi Gonzaga, Orbassano (TO)
| | - Chiara Lario
- S.C. Radiodiagnostica, Ospedale Mauriziano, Torino
| | - Paola Destefanis
- Divisione di Cardiologia, A.O.U. San Luigi Gonzaga, Orbassano (TO)
| | - Alessia Luciano
- Divisione di Cardiologia, A.O.U. San Luigi Gonzaga, Orbassano (TO)
| | - Enrico Cerrato
- Divisione di Cardiologia, A.O.U. San Luigi Gonzaga, Orbassano (TO)
| | - Carol Gravinese
- Divisione di Cardiologia, A.O.U. San Luigi Gonzaga, Orbassano (TO)
| | | | - Roberto Pozzi
- Divisione di Cardiologia, A.O.U. San Luigi Gonzaga, Orbassano (TO)
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Gunes H, Turan Sonmez F, Saritas A, Koksal Y. Kounis Syndrome Induced by Oral Intake of Diclofenac Potassium. Iran J Allergy Asthma Immunol 2017; 16:565-568. [PMID: 29338163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 12/23/2017] [Indexed: 06/07/2023]
Abstract
An acute coronary syndrome (ACS) occurring during the course of an allergic reaction is called Kounis syndrome (KS). The second case of KS induced by diclofenac potassium (DP) is presented in this report. A 67-year-old man was brought to our emergency department with the possible diagnosis of anaphylactic shock by the ambulance staff. It emerged that widespread erythema and pruritus developed after taking DP. Then, he lost consciousness. Diffuse urticarial lesions were detected on physical examination at the emergency department. He complained of chest pain during his observation, and progressive ST segment elevation was seen in the inferior leads on serial electrocardiograms. His coronary angiography showed 100% occlusion of the right coronary artery. Then, KS was diagnosed. The patient was discharged on the second day, and he was doing well on the control visit 2 weeks later. All allergic reactions may trigger an ACS so physicians should be aware of KS and always keep that unique clinical entity in mind to recognize it promptly and direct the therapy at suppressing the allergic reaction and improving the coronary circulation simultaneously when encountering a patient with symptoms suggesting an allergic reaction and a concomitant ACS.
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Affiliation(s)
- Harun Gunes
- Department of Emergency Medicine, School of Medicine, Duzce University, Duzce, Turkey
| | - Feruza Turan Sonmez
- Department of Emergency Medicine, School of Medicine, Duzce University, Duzce, Turkey
| | - Ayhan Saritas
- Department of Emergency Medicine, School of Medicine, Duzce University, Duzce, Turkey
| | - Yasin Koksal
- Department of Emergency Medicine, School of Medicine, Duzce University, Duzce, Turkey
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Blasco-Navalpotro MÁ, Orejas-Gallego A, Flordelís-Lasierra JL, Prior-Gómez N, Jiménez-Jiménez J, Seoane-Leston FJ. Coronary spasm secondary to biphasic anaphylaxis after hymenoptera stings. Ann Allergy Asthma Immunol 2016; 117:192-3. [PMID: 27263087 DOI: 10.1016/j.anai.2016.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/16/2016] [Indexed: 11/18/2022]
Affiliation(s)
| | - Alberto Orejas-Gallego
- Intensive Care Medicine Service, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | | | - Nieves Prior-Gómez
- Division of Allergy, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Juana Jiménez-Jiménez
- Division of Biochemistry, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
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