Ceftriaxone-induced Kounis syndrome: A case report and review of the literature

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.

Kounis syndrome: an underestimated emergency

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.

Unexpected cause of Kounis syndrome: hypersensitivity reaction to omeprazole

Kounis syndrome is a rare type of acute coronary syndrome (ACS) that occurs as a result of an allergic or anaphylactic reaction. Kounis syndrome can be induced by various medications including antibiotics, proton pump inhibitors, antihypertensive medications, corticosteroids, and antineoplastic medications. Additionally, cases of Kounis syndrome associated with lansoprazole and pantoprazole have been previously reported in the literature. In this report, we present a case of Kounis syndrome associated with omeprazole use, and discuss the need for a high index of suspicion as it is often underrecognised.

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.

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

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.

[Coronary anaphylaxis or Kounis syndrome]

Although not well known, Kounis syndrome represents 3.4 % of anaphylactic reactions and has a high level of mortality (7 %). Its main clinical presentation looks like an acute coronary syndrome. We report the case of a 61-year old patient who was admitted in the emergency department because of a malaise with loss of consciousness due to a Kounis syndrome that occurred after the ingestion of amoxycilline.

Kounis syndrome following an anaphylactic reaction to antivenom in a patient with Russell's viper (Daboia russelii) bite: A case report

Kounis syndrome is the occurrence of acute coronary syndrome associated with mast cell and platelet activation in the setting of allergic or anaphylactic insults. Kounis syndrome has been previously reported following snake envenoming rarely, with or without antivenom therapy. We report a case of inferolateral ST elevation myocardial infarction 32 hours from a confirmed Russell's viper bite. He also had an anaphylactic reaction soon after antivenom. The absence of underlying atheromatous coronary artery disease during subsequent cardiac imaging was suggestive of a diagnosis of a type I variant of Kounis syndrome. Chest pain completely resolved by day 6 following initiation of standard treatment for acute coronary syndrome. Concurrence of allergic features and acute coronary syndrome in a snakebite patient following antivenom therapy should alert clinicians to the possibility of Kounis syndrome, which should be diagnosed with a high degree of clinical suspicion.

Nursing care for patients with Kounis syndrome

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.

Iodinated contrast media induced Kounis syndrome during coronary angiogram: a life-threatening clinical dilemma

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.

Kounis Syndrome: Kill Two Birds With One Stone

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.

Allergic Myocardial Infarction: An Unusual Cause of Stent Thrombosis

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.

Type III Kounis syndrome after administration of an echocardiography contrast agent

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.

Insight into the Time Course of Type III Kounis Syndrome: A Case Report

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.

Kounis syndrome after patent blue dye injection for sentinel lymph node biopsy

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.

Rectosigmoid ischemia and cerebral coma following gadolinium-induced anaphylaxis: A new manifestation of Kounis syndrome presented as devastating complication

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.

Kounis syndrome following solenopsis (fire ant) bite

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.

[Kounis syndrome, the allergic acute coronary syndrome]

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.

An Acute Adverse Reaction with ST Elevation Induced by Magnetic Resonance Contrast Media: Kounis Syndrome

A 78-year-old man with mild coronary arteriosclerosis on coronary CT angiography underwent MRI of the prostate with the administration of Gadolinium-based contrast agent (GBCA) (gadopentetate dimeglumine). He developed acute coronary syndrome immediately after the intravenous injection of GBCA, and recovered after the administration of nitroglycerine, atropine sulfate, and hydrocortisone. He was discharged on the ninth day of hospitalization without recurrent chest symptoms. This is the second reported case of Kounis syndrome caused by GBCA. Kounis syndrome caused by MR contrast media is rare, but we should recognize that all contrast agents have the potential to cause Kounis syndrome.

Allergic acute coronary syndrome in exercise-induced anaphylaxis

In this case report we present a 49-year-old male who was seen in the emergency department after collapsing due to anaphylactic shock, with ECG findings suggesting myocardial ischaemia. We linked both diagnoses to Kounis syndrome, which describes an acute coronary syndrome due to an allergic event. His circulatory collapse was explained by exercise-induced anaphylaxis.

Kounis Syndrome Induced by Oral Intake of Diclofenac Potassium

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.

Death following ceftazidime-induced Kounis syndrome

Kounis syndrome, also known as allergic myocardial infarction or allergic angina syndrome, coincides with chest pain and allergic reactions. It involves the activation of interrelated inflammatory cells following allergic, anaphylactic or anaphylactoid insults. We report a case of Kounis syndrome complicated by an injection of ceftazidime. A 52-year-old man developed shortness of breath and hypotension, leading to immediate unconsciousness, after a ceftazidime injection. Despite intensive care management, he showed no improvement and died approximately 19 h after ceftazidime administration. Autopsy showed massive laryngeal oedema, mucous plugging and collapsed lungs. An ImmunoCAP tryptase assay showed the tryptase level in an autopsy sample to be 118 µg/L (normal < 11.4 µg/L). Microscopy of the myocardium showed cellular infiltration preceding myocardial necrosis. These findings support the pathophysiological theory of Kounis syndrome, with cellular infiltration proposed as the cause of myocardial injury rather than an effect related to the healing process.

[Inferior myocardial infarction complicated by complete heart block and cardiac arrest following a gadolinium injection: A case of Kounis syndrome]

Kounis syndrome is an allergic acute coronary syndrome. It occurs on healthy or pathological arteries. Its complications, although often benign, can lead to cardiac arrest and death. Its triggering factors are multiple and include contrast products used in diagnostic imaging. We report the case of an 81 years old patient affected by hepatocellular carcinoma, who presented a type 2 Kounis syndrome with inferior myocardial infarction, complicated by cardiac arrest related to complete heart block following a gadoteric acid injection.