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

542 Ceftriaxone-induced Kounis syndrome in the time of COVID-19

A 53 years old male subject with diabetes mellitus, hypertension, dyslipidaemia, obesity, and history of perianal abscess was admitted to the local hospital for generalized maculopapular rash on his trunk and limbs, which was accompanied by intense itching, sweating, hypotension, and severe chest pain. The rash and the accompanying signs/symptoms appeared 10 min after the administration of ceftriaxone (2 g) as antibiotic therapy for the perianal abscess. The patient had no clinical history for any type of allergy. At the first medical contact, an urgent electrocardiogram was taken showing ST-segment elevation in the anterior–lateral leads. The patient was still then treated with methylprednisolone and adrenalin i.v. as an anaphylactic shock was suspected. Afterwards, the patient was admitted in the emergency department, where he showed flu-like symptoms, chills, and fever. An echo-fast showed left ventricular wall motion abnormalities with hypokinesia of the anterior and posterior wall and moderate mitral regurgitation with normal EF. Laboratory tests showed increased levels of high-sensitivity cTnT (32.8 ng/l; NV &lt; 14), white blood cells (13.74 × 103/μl; NV 5.2–12.4 × 103), IL-6 (10.54 pg/ml; NV &lt; 7), C-reactive protein (PCR) (29.3 mg/l; NV 0–3). As for the cutaneous manifestations, flu-like symptoms, and blood test results (elevation of IL-6 and PCR despite an increase of white cell count) a SARS COV-2 swab was done. As recently noted in several preliminary studies, COVID-19 patients indeed show erythematous rash, and localized or widespread urticaria as initial manifestations in acute severe cases along with the humoural acute-phase response. The latter made it complicated to distinguish viral infection vs. drug administration as the underlying cause of the event. In the meantime, the patient started the treatment for an acute coronary syndrome and acetylsalicylic acid 100 mg, clopidogrel 300 mg orally, and enoxaparin dose subcutaneously were administered. Chest pain disappeared 30 min later and the ECG returned to normal 40 min after drug administration. Subsequently, the swab test result turned to be negative for SARS-CoV-2 and the patient was transferred to our centre for an emergency coronary angiography that revealed proximal subocclusive thrombotic stenosis and middle 70–80% thrombotic stenosis of the left anterior descending (LAD) coronary artery and a 80% thrombotic stenosis of the distal portion of the circumflex. Both vessels’ respective stenoses were treated with PCIs. When considering all together the anamnestic, laboratory, and instrumental/invasive findings, a case of Kounis Syndrome (KS) was suspected. Kounis syndrome (KS) has been indeed defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults mainly elicited by specific medications in male patients. KS involves the following three recognized variants: Type 1: the acute coronary event is secondary to spasm; Type 2: coronary thrombosis is the main culprit, and Type 3: the coronary event occurs secondary to drug-eluting stent thrombosis. Therefore, the patient was finally discharged with the diagnosis of ST-elevated MI likely secondary to a type II KS.

Kounis syndrome secondary to nimesulide ingestion: a case report

Background Kounis syndrome, also known as "allergic myocardial infarction," is a rare co-occurrence of acute coronary syndrome (ACS) in the setting of hypersensitivity reaction to any agent. Non-steroidal anti-inflammatory drugs (NSAIDs) like are often implicated in causing allergic reactions. Here, we present a case of anterior wall myocardial infarction (AWMI) occurred following angioedema secondary to intake of Nimesulide, not described earlier in literature. Case presentation A 45-year-old female developed generalized pruritic, erythematous maculopapular rash, facial puffiness, oral ulcers and hoarseness of voice within few hours following consumption of Nimesulide for fever and body-ache. Due to development of hypotension, electrocardiogram (ECG) was done, which revealed ST elevation in V2–V6, with marked elevation of troponin (TnI) and creatine kinase (CK-MB). He had no chest pain or shortness of breath. Echocardiography showed regional wall motion (RWMA) abnormality in left anterior descending artery (LAD) territory with an ejection fraction of 25%. Coronary angiography showed a complete thrombotic cutoff of LAD, for which Tirofiban infusion was started to decrease thrombus burden. Repeat angiography on next day showed 80% lesion in proximal LAD for which she underwent revascularization with a drug-eluting stent. The patient later showed improvement in cardiac function at 8 months of follow-up. Conclusions The occurrence of ACS requiring percutaneous coronary intervention (PCI) in the setting of allergic reactions is rarely reported in the literature. One should be aware of the rare possibility of Kounis syndrome in the setting of hypersensitivity reaction when accompanying features of symptoms suggestive of coronary artery disease co-exists. When indicated, ECG monitoring and cardiac biomarkers in patients with allergic responses help to identify this rare and treatable condition.