Case report
A rare cause of acute coronary syndrome: Kounis syndrome
Causa rara de síndrome coronária aguda: síndrome de Kounis
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The ACS was probably due to a hypersensitivity reaction. Myocardial infarction or angina secondary to an allergic reaction is known as Kounis syndrome.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">An 85-year-old man, white, a former smoker, had a history of hypertension, stage 4 chronic kidney disease, bladder cancer under follow-up, and allergy to quinolones. He was being medicated with hydroxyzine 25 mg daily and alprazolam 0.25 mg daily.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was admitted electively to the hospital for surgical circumcision and meatoplasty. During administration of ciprofloxacin in the operating theater he developed constricting chest discomfort associated with dyspnea, sweating and hypotension. Electrocardiographic monitoring showed apparent ST elevation, so ciprofloxacin was suspended and the patient was transferred to the hospital's emergency department. The electrocardiogram (ECG) revealed ST elevation (>3 mm) in DII, DIII and aVF, with ST depression and T-wave inversion in aVL and V1-V3 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given the suspicion of inferoposterior ST elevation ACS, he was medicated with a loading dose of ticagrelor (180 mg), aspirin 250 mg and morphine 8 mg and referred to our hospital for emergent catheterization. Coronary angiography, performed two hours after symptom onset, excluded coronary disease (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) and he was admitted to the cardiac intensive care unit. On admission he was asymptomatic and hemodynamically stable (blood pressure 112/67 mmHg) and the ECG showed sinus rhythm, right bundle branch block, and no ST-segment alterations (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Transthoracic echocardiography revealed no wall motion abnormalities or other relevant changes. Laboratory tests showed leukocytosis (11.72×10<span class="elsevierStyleSup">3</span>/μl, reference value 3.8-10.6×10<span class="elsevierStyleSup">3</span>/μl), neutrophilia (86.8%) and elevated C-reactive protein (5.24 mg/dl, reference value 0-0.5 mg/dl). These inflammatory parameters normalized within 24 hours. Assessment of cardiac biomarkers showed slight changes in high-sensitivity troponin T (falling from 0.051 to 0.035 ng/ml at 12 hours, reference value 0.003-0.014 ng/ml) and normal pro-B-type natriuretic peptide (102 pg/ml, reference value 0-450 pg/ml).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Given the absence of coronary disease, together with the patient's history of allergy to quinolones and the temporal association with ciprofloxacin administration, a diagnosis of allergic ACS (Kounis syndrome) was made. The patient was discharged after 24 hours of surveillance, medicated with long-acting oral nitrates, and there were no further events in two-month follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Kounis syndrome, also known as allergic angina and allergic myocardial infarction, is an ACS in the context of a hypersensitivity reaction.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> First described by Kounis in 1991,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> it appears to be related to the release of inflammatory mediators by mast cells in the course of an allergic reaction.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Among these mediators is histamine, which as well as inducing tissue factor expression and activating platelets, can trigger coronary vasospasm.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> The condition has been reported in the context of hypersensitivity to drugs, particularly antibiotics, non-steroidal anti-inflammatories and chemotherapy agents, and environmental exposure, such as to foods or insect bites.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Three subtypes of Kounis syndrome have been described<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a>: type I, due to coronary artery spasm in individuals without significant coronary disease; type II, in patients with pre-existing coronary disease, in whom the release of pro-inflammatory mediators causes vasospasm or atherosclerotic plaque instability; and type III, stent thrombosis due to a hypersensitivity reaction.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the case presented, the patient had a history of allergy to quinolones, and so previous sensitization may explain the speed with which the clinical setting developed. The absence of significant coronary disease led to this episode being classified as type I.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The clinical spectrum of Kounis syndrome is highly variable, and depends on the initial allergic response, the patient's comorbidities and susceptibilities (particularly history of atopia or autoimmune disease<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a>), and level of exposure to the allergen. It can affect children,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> and its severity ranges from transient episodes such as reported here to cases of cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">There is no consensus on treatment for Kounis syndrome, and most of the data on it are from case reports. At all events, the therapeutic strategy depends on the subtype.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> In type I, treating the allergic reaction should resolve the ACS if this has not occurred spontaneously on withdrawal of the allergen, as in the case presented, in which the only action was immediate suspension of the drug, without any anti-allergic treatment. In types II and III, it is also necessary to treat the ACS.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> In addition to standard ACS treatment,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> the vasospasm should be treated with vasodilators (nitrates and non-dihydropyridine calcium channel blockers). Treatment of the allergic reaction includes anti-histamines and epinephrine,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> although the latter should be considered on a case-by-case basis depending on the severity of the anaphylactic reaction, given the simultaneous presence of an ACS.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Kounis syndrome is a diagnosis to be borne in mind in cases of suspected ACS in the context of an allergic reaction. The mechanisms of this condition are not fully understood, but treatment should be directed at the hypersensitivity reaction and the coronary event, in accordance with the results of coronary angiography.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres798205" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec796178" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres798204" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec796177" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-03" "fechaAceptado" => "2016-03-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec796178" "palabras" => array:4 [ 0 => "Kounis syndrome" 1 => "Acute coronary syndrome" 2 => "Coronary vasospasm" 3 => "Allergy" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec796177" "palabras" => array:4 [ 0 => "Síndrome de Kounis" 1 => "Síndrome coronária aguda" 2 => "Vasospasmo coronário" 3 => "Alergia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kounis syndrome is an acute coronary syndrome in the context of a hypersensitivity reaction. The main pathophysiological mechanism appears to be coronary vasospasm.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a patient with a history of allergy to quinolones, who was given ciprofloxacin before an elective surgical procedure and during drug administration developed symptoms and electrocardiographic changes suggestive of ST-segment elevation acute coronary syndrome. The drug was suspended and coronary angiography excluded epicardial coronary disease. Two hours after withdrawal of the drug the symptoms and ST elevation had resolved completely.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A síndrome de Kounis corresponde a uma síndrome coronária aguda em contexto de reação de hipersensibilidade. O mecanismo fisiopatológico principal parece estar relacionado com vasospasmo coronário. Apresentamos o caso de um doente com história de alergia a quinolonas, ao qual foi administrado ciprofloxacina antes de um procedimento cirúrgico eletivo e que, durante a administração do fármaco, desenvolve quadro sugestivo de síndrome coronária aguda com supradesnivelamento de ST. O fármaco foi suspenso e a realização de cateterismo cardíaco emergente revelou ausência doença coronária epicárdica. Duas horas após a interrupção do fármaco, o quadro clínico resolveu completamente.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Almeida J, Ferreira S, Malheiro J, Fonseca P, Caeiro D, Dias A, et al. Causa rara de síndrome coronária aguda: síndrome de Kounis. Rev Port Cardiol. 2016;35:699.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 777 "Ancho" => 1599 "Tamanyo" => 161318 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram following symptom onset.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 740 "Ancho" => 1501 "Tamanyo" => 118660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 805 "Ancho" => 1601 "Tamanyo" => 201596 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram following coronary angiography.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. 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| 2022 January | 36 | 28 | 64 |
| 2021 December | 28 | 35 | 63 |
| 2021 November | 52 | 35 | 87 |
| 2021 October | 44 | 52 | 96 |
| 2021 September | 29 | 25 | 54 |
| 2021 August | 42 | 34 | 76 |
| 2021 July | 36 | 28 | 64 |
| 2021 June | 34 | 29 | 63 |
| 2021 May | 37 | 43 | 80 |
| 2021 April | 92 | 54 | 146 |
| 2021 March | 125 | 39 | 164 |
| 2021 February | 143 | 25 | 168 |
| 2021 January | 65 | 25 | 90 |
| 2020 December | 66 | 9 | 75 |
| 2020 November | 63 | 14 | 77 |
| 2020 October | 41 | 18 | 59 |
| 2020 September | 70 | 24 | 94 |
| 2020 August | 50 | 9 | 59 |
| 2020 July | 70 | 13 | 83 |
| 2020 June | 52 | 15 | 67 |
| 2020 May | 65 | 9 | 74 |
| 2020 April | 60 | 9 | 69 |
| 2020 March | 67 | 21 | 88 |
| 2020 February | 125 | 70 | 195 |
| 2020 January | 69 | 6 | 75 |
| 2019 December | 47 | 15 | 62 |
| 2019 November | 57 | 6 | 63 |
| 2019 October | 63 | 11 | 74 |
| 2019 September | 96 | 12 | 108 |
| 2019 August | 69 | 14 | 83 |
| 2019 July | 42 | 10 | 52 |
| 2019 June | 54 | 12 | 66 |
| 2019 May | 72 | 7 | 79 |
| 2019 April | 46 | 17 | 63 |
| 2019 March | 120 | 12 | 132 |
| 2019 February | 113 | 9 | 122 |
| 2019 January | 99 | 9 | 108 |
| 2018 December | 79 | 15 | 94 |
| 2018 November | 106 | 29 | 135 |
| 2018 October | 179 | 27 | 206 |
| 2018 September | 66 | 18 | 84 |
| 2018 August | 28 | 8 | 36 |
| 2018 July | 48 | 6 | 54 |
| 2018 June | 64 | 3 | 67 |
| 2018 May | 87 | 20 | 107 |
| 2018 April | 86 | 17 | 103 |
| 2018 March | 98 | 16 | 114 |
| 2018 February | 62 | 8 | 70 |
| 2018 January | 77 | 13 | 90 |
| 2017 December | 150 | 7 | 157 |
| 2017 November | 80 | 9 | 89 |
| 2017 October | 40 | 13 | 53 |
| 2017 September | 51 | 24 | 75 |
| 2017 August | 46 | 17 | 63 |
| 2017 July | 39 | 9 | 48 |
| 2017 June | 50 | 33 | 83 |
| 2017 May | 47 | 28 | 75 |
| 2017 April | 23 | 23 | 46 |
| 2017 March | 40 | 59 | 99 |
| 2017 February | 48 | 23 | 71 |
| 2017 January | 57 | 28 | 85 |
| 2016 December | 101 | 54 | 155 |
| 2016 November | 9 | 22 | 31 |
Show all
