Metamizole-Induced Type I Kounis Syndrome

Kounis syndrome (KS) is defined as acute coronary syndrome (ACS) triggered by mast cell and platelet activation in the setting of allergic or anaphylactic insults. KS is a unique and complex cause of ACS and many cases may be missed due to its highly variable clinical manifestations. In this report, we present a case of KS type I triggered by metamizole in the absence of a previous history of allergy to this drug. Following the administration of metamizole, the patient developed generalized acute urticaria, chest pain and diaphoresis. Electrocardiography (ECG) showed ST-segment elevation suggestive of myocardial infarction complicated by ventricular tachycardia. No coronary disease was observed on coronary angiography. The cardiac manifestations of KS may be life-threatening, and so it is important to appropriately recognize and treat this condition.

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A rare case of acute alcohol intoxication mimicking an electrocardiographic pattern for acute coronary syndrome with ST-segment elevation

Emergency Care Journal ◽

10.4081/ecj.2020.8596 ◽

2020 ◽

Vol 16 (1) ◽

Author(s):

Franco Lai ◽

Lorenzo Pelagatti ◽

Chiara Pagnini ◽

Alessio Baldini ◽

Daniele Versari ◽

...

Keyword(s):

Alcohol Intoxication ◽

Coronary Spasm ◽

Cyclic Guanosine Monophosphate ◽

Guanosine Monophosphate ◽

Pathophysiological Mechanism ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Threatening Condition ◽

Life Threatening

A patient presenting an ST-segment elevation could represent a life-threatening condition in Emergency Department (ED). This case shows how sometimes, a chronic, and more often, an acute abuse of alcohol is related to important harmful effects on myocardial contractility. The authors present a case of a 19-year-old male of oriental-Asiatic origin admitted unconscious to ED with alcoholic fetor: on electrocardiogram a significant and widespread STsegment elevation was observed. A bedside echocardiography showed no abnormalities in segmental kinetics; therefore electrocardiogram- alterations could be related to a coronary spasm. The literature is poor about this effect induced by acute alcohol ingestion: the pathophysiological mechanism at the base of the abnormal muscle contractility, seems to be related to an impairment in cyclic guanosine monophosphate production, although a second and less probable hypothesis could be an altered intracellular concentration of calcium levels.

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Allergy Associated Myocardial Infarction: A Comprehensive Report of Clinical Presentation, Diagnosis and Management of Kounis Syndrome

Vaccines ◽

10.3390/vaccines10010038 ◽

2021 ◽

Vol 10 (1) ◽

pp. 38

Author(s):

Anastasios Roumeliotis ◽

Periklis Davlouros ◽

Maria Anastasopoulou ◽

Grigorios Tsigkas ◽

Ioanna Koniari ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Arteries ◽

Case Reports ◽

Type I ◽

Type Ii ◽

Kounis Syndrome ◽

Normal Coronary Arteries ◽

St Segment Elevation ◽

Type Iii ◽

Coronary Syndrome

Kounis syndrome (KS) has been defined as acute coronary syndrome (ACS) in the context of a hypersensitivity reaction. Patients may present with normal coronary arteries (Type I), established coronary artery disease (Type II) or in-stent thrombosis and restenosis (Type III). We searched PubMed until 1 January 2020 for KS case reports. Patients with age <18 years, non-coronary vascular manifestations or without an established diagnosis were excluded. Information regarding patient demographics, medical history, presentation, allergic reaction trigger, angiography, laboratory values and management were extracted from every report. The data were pulled in a combined dataset. From 288 patients with KS, 57.6% had Type I, 24.7% Type II and 6.6% Type III, while 11.1% could not be classified. The mean age was 54.1 years and 70.6% were male. Most presented with a combination of cardiac and allergic symptoms, with medication being the most common trigger. Electrocardiographically, 75.1% had ST segment elevation with only 3.3% demonstrating no abnormalities. Coronary imaging was available in 84.8% of the patients, showing occlusive lesions (32.5%), vascular spasm (16.2%) or normal coronary arteries (51.3%). Revascularization was pursued in 29.4% of the cases. In conclusion, allergic reactions may be complicated by ACS. KS should be considered in the differential diagnosis of myocardial infarction with non-obstructive coronary arteries.

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Kounis syndrome – an unusual etiology of acute myocardial infarction

Romanian Journal of Medical Practice ◽

10.37897/rjmp.2015.3.15 ◽

2015 ◽

Vol 10 (3) ◽

pp. 295-299

Author(s):

Vlad BĂTĂILĂ ◽

◽

Aura VÎJÎIAC ◽

Lucian CÂLMÂC ◽

Maria DOROBANŢU ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Conservative Approach ◽

Inferior Myocardial Infarction ◽

Kounis Syndrome ◽

Wasp Sting ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Vasoactive Mediators ◽

St Segment

Kounis syndrome is defined as an association between an acute coronary syndrome and acute systemic allergy involving vasoactive mediators released during the activation of the mast cells. A 79 year old woman arrives at the emergency department with syncope; she was stung by a wasp an hour before symptoms’ onset. Clinical examination was normal, excepet her left upper limb which had important edema. The ECG revealed ST-segment elevation in the inferior leads and negative T waves in the anterior leads. Emergency coronary angiography was performed, which revealed a 40% stenotic plaque on the mid LAD. A conservative approach was decided. The patient received standard anti-ischemic treatment and she was safely discharged after 6 days. We considered this case a Kounis syndrome induced by a wasp sting associated with a silent inferior myocardial infarction.

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Lithium-induced ECG modifications: navigating from acute coronary syndrome to Brugada syndrome

BMJ Case Reports ◽

10.1136/bcr-2021-241555 ◽

2021 ◽

Vol 14 (6) ◽

pp. e241555

Author(s):

Léonard Diserens ◽

Alessandra Pia Porretta ◽

Catalina Trana ◽

David Meier

Keyword(s):

Brugada Syndrome ◽

Bipolar Disorders ◽

Therapeutic Modality ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Frequent Monitoring ◽

St Segment ◽

Life Threatening ◽

Ecg Alterations

Lithium is frequently used in the treatment of bipolar disorders and is known to induce ECG alterations. This case study describes various patterns of lithium-induced ECG modifications in a patient with acute-on-chronic lithium intoxication. Clinicians should be familiar with this problem as it can have life-threatening consequences and lead to important changes in patient’s management. Our patient was admitted for acute delirium with an ECG showing atrial fibrillation with wide QRS and ST-segment elevation. These modifications were first mistaken for an acute myocardial infarction and a diagnosis of Brugada syndrome was finally reached. Treatment after the acute phase implied changes in the therapeutic modality and required frequent monitoring.

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Uncommon but imperative cause of repeated acute stent thrombosis: Kounis syndrome type III

BMJ Case Reports ◽

10.1136/bcr-2020-240704 ◽

2021 ◽

Vol 14 (3) ◽

pp. e240704

Author(s):

Shiro Miura ◽

Takehiro Yamashita ◽

Masaki Murata ◽

Nicholas G Kounis

Keyword(s):

Stent Thrombosis ◽

Pathological Examination ◽

Syndrome Type ◽

Kounis Syndrome ◽

St Segment Elevation ◽

Type Iii ◽

Coronary Syndrome ◽

St Segment ◽

History Of ◽

Acute Stent Thrombosis

A 69-year-old woman with a history of allergic reactions to unknown metals who presented 1 year prior with acute coronary syndrome complicated by acute stent thrombosis (ST) was admitted due to new-onset chest pain during mild exercise. She electively underwent coronary angiography, revealing a newly developed stenosis in the fourth branch of the posterior descending artery, treated with an everolimus-eluting stent. One hour later, she reported of sudden chest tightness and nausea; ECG revealed significant ST-segment elevation in the II, III and aVF leads. We suspected ST-segment elevation myocardial infarction resulting from an allergic reaction (ie, Kounis syndrome type III) and managed it properly by eliminating other potential causes. The tentative diagnosis was confirmed by pathological examination of aspirated materials. Kounis syndrome type III may be a frequently undiagnosed clinical entity, emphasising the importance of pathological examination of aspirated materials when implanting coronary stents and history-taking of allergies to stent metals.

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Case Report: Phloroglucinol-Induced Kounis Syndrome

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.668318 ◽

2021 ◽

Vol 8 ◽

Author(s):

Hao-Yu Wu ◽

Tian-Jiao Gao ◽

Yi-Wei Cao ◽

Peng-Hua You

Keyword(s):

Chest Pain ◽

Coronary Artery ◽

Right Coronary Artery ◽

Troponin I ◽

Plaque Rupture ◽

Type Ii ◽

Kounis Syndrome ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment

Background: Kounis syndrome is an allergy-related acute coronary syndrome that is induced by various pharmacological and environmental factors. Given that many clinicians are not aware of this condition, many cases may be underdiagnosed. We report a case of type II Kounis syndrome induced by phloroglucinol.Case Summary: A 52-year-old man with pre-existing coronary artery stenosis presented with a 30-min history of chest pain and erythematous rash after intramuscular administration of phloroglucinol. An electrocardiogram demonstrated ST-segment elevation in leads II, III and aVF. Emergency coronary angiography revealed severe stenosis in the distal right coronary artery. Intravascular ultrasound showed plaque rupture and thrombosis, and the minimum lumen area was 3.0 mm2. A 3.5 × 38 mm stent was implanted in the distal right coronary artery. Troponin I levels were elevated. A diagnosis of type II Kounis syndrome induced by phloroglucinol was made, and the condition manifested as acute ST-segment elevation myocardial infarction.Conclusions: Clinicians should be aware of Kounis syndrome as a possible diagnosis in a patient who presents with chest pain and allergic manifestations given that an increasing number of triggers are being reported.

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Kounis Syndrome Secondary to Medicine-Induced Hypersensitivity

Case Reports in Medicine ◽

10.1155/2021/4485754 ◽

2021 ◽

Vol 2021 ◽

pp. 1-6

Author(s):

Parackrama Karunathilake ◽

Udaya Ralapanawa ◽

Thilak Jayalath ◽

Shamali Abeyagunawardena

Keyword(s):

Allergic Reaction ◽

Troponin I ◽

Complete Recovery ◽

Isosorbide Mononitrate ◽

Kounis Syndrome ◽

Coronary Syndrome ◽

St Segment ◽

Daily Dose ◽

Threatening Condition ◽

Life Threatening

Introduction. Kounis syndrome is the concurrence of an acute coronary syndrome (ACS) caused by coronary vasospasms, acute myocardial infarctions, or stent thromboses in case of allergic or hypersensitivity reactions. Kounis syndrome is mediated by mast cells that interact with macrophages and T-lymphocytes, causing degranulation and inflammation with cytokine release. It is a life-threatening condition that has many trigger factors and is most commonly caused by medicines. Case Presentation. A 71-year-old male was admitted with a fever of five days’ duration associated with cellulitis, for which he had been treated with clindamycin and flucloxacillin before admission. He was a diagnosed patient with hypertension and dyslipidemia five years ago. After taking the antibiotics, he had developed generalized itching followed by urticaria suggesting an allergic reaction. Therefore, he was admitted to the hospital. After admission, he developed an ischaemic-type chest pain associated with autonomic symptoms and shortness of breath. An immediate ECG was taken that showed ST-segment depressions in the chest leads V4–V6, confirmed by a repeat ECG. Troponin I was 8 ng/mL. Acute management of ACS was started, and prednisolone 10 mg daily dose was given. After complete recovery, the patient was discharged with aspirin, clopidogrel, atorvastatin, metoprolol, losartan, isosorbide mononitrate, and nicorandil. Prednisolone 10 mg daily dose was given for five days after discharge. Conclusion. In immediate hypersensitivity, with persistent cardiovascular instability, Kounis syndrome should be considered, and an electrocardiogram and other appropriate assessments and treatments should be initiated. Prompt management of the allergic reaction and the ACS is vital for a better outcome of Kounis syndrome.

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Acute Coronary Syndrome

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0028 ◽

2019 ◽

pp. 190-196

Author(s):

Siva S. Ketha ◽

Juan Carlos Leoni Moreno

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Plaque Rupture ◽

Clinical Manifestations ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Atherosclerotic Plaque Rupture

Acute coronary syndrome (ACS) encompasses all clinical manifestations caused by active myocardial ischemia and includes 3 entities: unstable angina (UA), acute non–ST-segment elevation myocardial infarction (NSTEMI), and acute ST-segment elevation myocardial infarction (STEMI). Atherosclerotic plaque rupture is the most consistent pathophysiologic event in ACS. After plaque rupture, cardiac myocytes die as a consequence of continued occlusion, thereby causing acute myocardial infarction (MI). Prompt recognition of ACS is crucial because the greatest therapeutic effect is achieved if treatment is performed soon after presentation.

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MIF mRNA Expression and Soluble Levels in Acute Coronary Syndrome

Cardiology Research and Practice ◽

10.1155/2018/9635652 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Emmanuel Valdés-Alvarado ◽

Yeminia Valle ◽

José Francisco Muñoz-Valle ◽

Ilian Janet García-Gonzalez ◽

Angelica Valdez-Haro ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Mrna Expression ◽

Clinical Manifestations ◽

Serum Levels ◽

Enzyme Linked Immunosorbent Assay ◽

Control Group ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Myocardial Infraction

Acute coronary syndrome (ACS) describes any condition characterized by myocardial ischaemia and reduction in blood flow. The physiopathological process of ACS is the atherosclerosis where MIF operates as a major regulator of inflammation. The aim of this study was to assess the mRNA expression of MIF gene and its serum levels in the clinical manifestations of ACS and unrelated individuals age- and sex-matched with patients as the control group (CG). All samples were run using the conditions indicated in TaqMan Gene Expression Assay protocol. Determination of MIF serum levels were performed by enzyme-linked immunosorbent assay and MIF ELISA Kit. ST-segment elevation myocardial infraction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) showed 0.8 and 0.88, respectively, less expression of MIF mRNA with regard to CG. UA and STEMI presented more expression than NSTEMI 5.23 and 0.68, respectively. Otherwise, ACS patients showed significant higher MIF serum levels (p=0.02) compared with CG. Furthermore, the highest soluble levels of MIF were presented by STEMI (11.21 ng/dL), followed by UA (10.34 ng/dL) and finally NSTEMI patients (8.75 ng/dL); however, the differences were not significant. These novel observations further establish the process of MIF release after cardiovascular events and could support the idea of MIF as a new cardiac biomarker in ACS.

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ST-Segment Elevation and Normokalemia in Acute Diabetic Ketoacidosis: Case Report and Brief Literature Review

International Journal of Medical Students ◽

10.5195/ijms.2020.432 ◽

2020 ◽

Vol 8 (1) ◽

pp. 33-35

Author(s):

S. Bryn Dhir ◽

Abbas Husain

Keyword(s):

Diabetic Ketoacidosis ◽

Diabetes Mellitus Type 1 ◽

Normal Serum ◽

Diabetic Patients ◽

Valuable Insight ◽

St Segment Elevation ◽

St Segment ◽

Life Threatening ◽

History Of ◽

Cardiac Manifestations

Background: Diabetic Ketoacidosis (DKA) is a life-threatening complication of Diabetes Mellitus Type 1 (DM1) and requires prompt management; however, benign transient electrocardiographic (ECG) abnormalities with normal serum potassium levels can be seen in diabetic patients secondary to metabolic changes. Understanding the varying presentation among patients provides valuable insight into the management of this seemingly uncommon and benign diagnosis. The Case: A 24-year-old male with a history of DM1 presented to the Emergency Department (ED) with ST-segment elevation, normal potassium levels and metabolic acidosis. The patient was found to be in DKA with benign cardiac manifestations. Conclusion: The correction of underlying metabolic abnormalities in DKA and the awareness of the benign cardiac pseudo pathology on ECG allows for effective management and personalized patient care.

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