Letter to the Editor
Kounis syndrome: A manifestation of drug-eluting stent thrombosis associated with allergic reaction to contrast material

https://doi.org/10.1016/j.ijcard.2008.08.026Get rights and content

Abstract

Stent components acting as potential antigens and promoting intracoronary mast cell activation can lead to catastrophic intrastent thrombosis. Patients with drug-eluting stent (DES) implantation are prone to hypersensitivity reactions from five potential antigens namely, nickel strut, polymer coating, eluted drug, as well as, concomitant drugs clopidogrel and aspirin. These events may be more common than suspected because it is hard to document them, unless they become systemic, in which case they manifest themselves as the Kounis syndrome characterized by the concurrence of acute coronary events with hypersensitivity reactions. This report concerns of a patient with implanted DES who developed an acute myocardial infarction in the stent area following an allergic reaction to contrast material.

Introduction

Acute myocardial infarction following stent implantation is an emerging serious clinical problem in patients treated with DES [1]. Recent data have shown that a small but increasing number of patients, with implanted DES, may develop simultaneous, multivessel, repeated, remote and peripheral arterial thrombosis [2]. Clinical and pathology findings point towards a possible hypersensitivity reaction to DES components manifesting as Kounis syndrome [3]. Current DES components include the metal stent itself which is made from 316L stainless steel containing nickel, chromium, molybdenum, the polymer coating, and the impregnated drugs which for today are: the antimicrotubule, antineoplastic agent paclitaxel and the anti-inflammatory, immunosuppressive and antiproliferative agent rapamycin. For Endeavor zotarolimus-eluting stent which is a newly synthesized sirolimus analogue and received FDA approval recently long results and side effects from its use have not been established [4]. Other agents such as everolimus, biolimus, tacrolimus pimecrolimus etc. are currently undergoing safety and efficacy trials either impregnated in metal stents or used in transplant recipients in order to prevent rejection. All these agents either separately or synergistically seem to be able to induce hypersensitivity reactions and hypersensitivity coronary events [4]. Additionally, patients we implanted stents, receive clopidogel and aspirin, two well known antigenic substances, as antiplatelet agents.

We report a patient who developed acute myocardial infarction, in the stented coronary area, following allergic reaction to an additional antigenic agent (a non-anionic contrast material) during radiographic examination.

Section snippets

Case report

A 48-year-old heavy smoker man was referred for investigation for recurrent renal colic and low back pain. During his admission routine laboratory investigation revealed no abnormality and he was scheduled for abdominal contrast-enhanced CT-scan and intravenous urography. The patient did not recall any previous history of drug allergy, rhinitis, eczema, dermatitis, bronchial asthma and diabetes mellitus.

However, six months previously he had been admitted to another hospital for an acute

Discussion

Patients undergoing DES implantation receive five different substances which can act as potential antigens. These substances include the nickel strut, the polymer, the eluted drug, plus aspirin and clopidogrel. Hypersensitivity inflammation is initiated by antigens cross-bridging their corresponding, receptor-bound, immunoglobulin IgE antibodies on the mast cell or basophile cell surface. These cells degranulate and release their mediators when the critical number of bridged IgE antibodies

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [15].

References (15)

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