Letter to the Editor
Coronary spasm and hypersensitivity to amoxicillin: Kounis or not Kounis syndrome?

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Abstract

Several reports have suggested that the onset of allergic phenomena in predisposed subjects may trigger an angina episode, and this association has been described as Kounis syndrome. However, no previous reports have convincingly demonstrated a causal relationship between allergic reactions and acute coronary syndrome, and other possible mechanisms have not been excluded as causes of angina onset. We present a patient with chronic metabolic acidosis because of ureteroileourethrostomy and history of hypersensivity to beta-lactamic agents. He suffered three episodes of documented vasospastic angina, two of them related to amoxicillin administration; however, worsening of metabolic acidosis was found in all three episodes. This report shows that although allergic phenomena could play a role triggering this kind of acute coronary syndrome, other uncommon underlying mechanisms should be considered before the diagnosis of Kounis syndrome is established.

Introduction

It has been recently described that the onset of allergic phenomena in predisposed subjects can trigger an angina episode [1], [2]. The association of acute coronary syndrome and hypersensitivity reactions has been described as Kounis syndrome [3]. Furthermore, two variants of this syndrome are recognized in previous reports. Type I happens in patients with normal coronary arteries, which might represent a manifestation of endothelial dysfunction or microvascular angina. In type II, coronary spasm occurs in patients with culprit but quiescent pre-existing atheromatous disease [2], [3].

Several authors have reported coincidental occurrence of allergic reactions accompanied by clinical and laboratory findings of angina. Although some studies have found elevation of histamine and other markers of mast cell activation [4], none of them have demonstrated a causal relation between allergic reaction and acute coronary syndrome, and other common or uncommon mechanisms of angina have not been systematically ruled out [5].

Section snippets

Case report

A 69-year-old male, smoker, with a previous history of Raynaud syndrome, underwent a radical cystectomy with reconstruction by Studer's technique (ureteroileourethrostomy) because of a vesical neoplasy in 2003. After surgery, he presented a urinary tract infection managed with intravenous amoxicillin. Few minutes after the first dose, patient had an episode of epigastric discomfort that progressed to oppressive centrothoracic pain radiated to both upper limbs, lasting for 30 min and accompanied

Discussion

Vasoespastic angina represents approximately 2% of all episodes of unstable angina. It is more frequent in 40- to 50-year-old males, smokers, and typically presented as short episodes at rest that usually respond to calcium antagonists and/or nitrates [5]. Pathophysiology of coronary spasm involves a local hyperreactivity of a coronary segment to a vasoconstrictor stimulus. Previous reports have suggested a possible association between allergic reactions and acute coronary syndrome, which has

References (6)

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