Treatment of Kounis syndrome

doi:10.1016/j.ijcard.2010.02.040

International Journal of Cardiology

Volume 143, Issue 3, 3 September 2010, Pages 223-226

https://doi.org/10.1016/j.ijcard.2010.02.040 Get rights and content

Abstract

Kounis syndrome is potentially a life-threatening medical emergency with both a severe allergic reaction and acute coronary syndrome. Most of the information about this syndrome has come from the case reports. The management of these patients may be challenging for clinicians, and unfortunately guidelines have not been established yet. In this article, we review the current guidelines of acute coronary syndromes and anaphylaxis along with the published cases with Kounis syndrome secondary to beta-lactam antibiotics. We have summarized our recommendations for the work-up and treatment of Kounis syndrome from available data. Obviously, larger prospective studies are needed to establish definitive treatment guidelines for these patients.

Introduction

The acute onset of chest pain accompanied by allergic symptoms should raise suspicion for the possibility of Kounis syndrome. This is not a simple situation, and the diagnosis and management may be challenging since the evaluation and treatment need to consider both cardiac and allergic syndromes simultaneously. The initial cardiac studies include the routine diagnostic tests for patients with acute coronary syndromes (ECG and cardiac enzymes). The allergy work-up includes assays for serum histamine, tryptase, IgE antibody, and complement proteins (C4 and C1-esterase inhibitor levels) and eosinophil counts. Elevated serum histamine and tryptase levels strongly support the possibility of an ongoing allergic reaction, but these molecules have very short half lives (less than 10 min for histamine and 90 min for tryptase) that make them(especially histamine) relatively impractical for routine use. A normal tryptase level does not exclude this possibility. Eventually these patients will need cardiac catheterization to assess the coronary anatomy, to possibly relieve vasospasm directly with intracoronary agents, and to perform angioplasty when needed. Patients with a clinical suspicion of type 2 Kounis syndrome should also have intracoronary ultrasound to identify occult coronary artery disease. This is important since the detection of nonobstructive coronary plaques would necessitate long term treatment with plaque stabilizing drugs, such as statins and anti-platelet drugs. During the follow-up, patients may need additional allergy work-up, including skin prick tests.

Section snippets

Management of acute coronary syndrome

Based on the current ACC/AHA guidelines on acute coronary syndromes, the common medications are discussed individually for their therapeutic benefits and risks in patients with Kounis syndrome [1].

Recommendations

Acute coronary syndromes secondary to allergic reactions are associated with significant morbidity and mortality in hypersensitive individuals. The systemic allergic response caused by inflammatory mediators should be controlled early in the management of these patients.

1.
All patients should be questioned carefully regarding their allergy profile before their treatment with a potentially allergic drug such as a beta-lactam antibiotic.
2.
Kounis syndrome should be considered in young, healthy patients

Summary

Kounis syndrome is a complex acute coronary syndrome which requires rapid treatment decisions. Most of the information on this syndrome comes from case reports or small case series. Controlled trials will never be done given the complexity of the presentation. We recommend the establishment of an international registry to collect standardized information on these patients.

Conflict of interest

None.

Acknowledgement

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

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Ceftriaxone-induced Kounis syndrome: A case report and review of the literature
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El síndrome de Kounis viene definido por los síntomas cardiovasculares que se producen de manera secundaria a episodios alérgicos o de hipersensibilidad, denominándose también angina alérgica e infarto de miocardio alérgico. Reportamos un caso de síndrome de Kounis preoperatorio inducido por ceftriaxona, sin manifestación dermatológica evidente, y describimos nuestro dilema diagnóstico. La paciente fue manejada sintomáticamente y dada de alta en situación estable, con advertencia sobre el uso futuro de ceftriaxona.
Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.
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Hymenoptera heartaches -cardiac manifestation with hymenoptera stings, a retrospective study from a tertiary care hospital in South India
2021, American Journal of Emergency Medicine
Hymenoptera stings usually have a multitude of presentations from very subtle to life-threatening conditions. Various cardiac manifestations including Kounis syndrome often get missed due to lack of suspicion. The aim of the study was to describe the clinical profile of the cardiac etiologies associated with hymenoptera stings and review literature with focus on diagnosis and treatment strategies.
A retrospective chart analysis was performed including all adult patients who had a hymenoptera sting during a two-year window (October 2018 – October 2020). Of these, patients with cardiac features were enrolled. A structured case record form was used to capture information like basic demography, clinical profile, and outcomes.
Thirteen cases presented with hymenoptera stings of which six cases had cardiac presentation and were considered. The most common presentations were breathlessness and generalised itching with only one patient complaining of chest pain. All patients(with available data) had ECG changes suggestive of ischemia and associated raised troponin levels with 2D echo changes. The diagnoses considered included Kounis syndrome, hypersensitivity myocarditis, and Takotsubo cardiomyopathy. Patients were managed conservatively with one patient undergoing a coronary angiography. All patients were stable at discharge.
Cardiac manifestations with hymenoptera stings although rare may complicate diagnosis and treatment.It should be borne in mind during assessment and standardised guidelines should be developed for ED treatment such as the one recommended in this study. Keywords:Hymenoptera, Kounis syndrome, Acute Coronary Syndrome, emergency medicine.
Type 1 Kounis Syndrome Induced by Inactivated SARS-COV-2 Vaccine
2021, Journal of Emergency Medicine
Background Vaccination is the most important way out of the novel coronavirus disease 2019 (COVID-19) pandemic. Vaccination practices have started in different countries for community immunity. In this process, health authorities in different countries have preferred different type of COVID-19 vaccines. Inactivated COVID-19 vaccine is one of these options and has been administered to more than 7 million people in Turkey. Inactivated vaccines are generally considered safe. Kounis syndrome (KS) is a rare clinical condition defined as the co-existence of acute coronary syndromes and allergic reactions.
Case Report We present the case of a 41-year-old woman with no cardiovascular risk factors who was admitted at our emergency department with flushing, palpitation, dyspnea, and chest pain 15 min after the first dose of inactivated CoronaVac (Sinovac Life Sciences, Beijing, China). Electrocardiogram (ECG) showed V4-6 T wave inversion, and echocardiography revealed left ventricular wall motion abnormalities. Troponin-I level on arrival was elevated. Coronary angiography showed no sign of coronary atherosclerosis. She was diagnosed with type 1 KS. The patient's symptoms resolved and she was discharged from hospital in a good condition.
Why Should an Emergency Physician Be Aware of This? To the best of our knowledge, this is the first case of allergic myocardial infarction secondary to inactivated coronavirus vaccine. This case demonstrates that KS can occur after inactivated virus vaccine against COVID-19. Although the risk of severe allergic reaction after administration of CoronaVac seems to be very low, people who developed chest pain after vaccine administration should be followed by ECG and troponin measurements.
Vancomycin-induced Kounis Syndrome
2019, American Journal of Emergency Medicine
Kounis Syndrome is a rare allergic reaction that results in coronary vasospasm and may occur in patients with and without coronary artery disease. A 57-year-old man receiving pre-operative vancomycin for osteomyelitis and gangrene of the foot experienced an episode of anginal symptoms associated with transient ischemic 12-lead electrocardiogram (ECG) changes. The patient's symptoms and ECG changes abated with discontinuation of vancomycin and subsequent coronary angiography revealed no evidence of coronary artery disease. Treatment of Kounis Syndrome begins with cessation of the causative agent. Consensus guidelines for the management of Kounis Syndrome have not been established but treatment should both dilate the coronary vessels and suppress the allergic response. Coronary vasospasm after administration of antibiotics, including vancomycin, is a rare but serious reaction. It is important that Emergency Physicians recognize Kounis Syndrome as an uncommon yet dramatic and consequential reaction to such a commonly-administered antibiotic.

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ReviewTreatment of Kounis syndrome

Abstract

Introduction

Section snippets

Management of acute coronary syndrome

Recommendations

Summary

Conflict of interest

Acknowledgement

J Allergy Clin Immunol

Ann Emerg Med

Am J Cardiol

Int J Cardiol

Guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction

J Am Coll Cardiol

Anaphylactic and anaphylactoid reactions to aspirin and other NSAIDs

Clin Rev Allergy Immunol

Allergic and nonallergic reactions to nitroglycerin

Allergy Asthma Proc

Review
Treatment of Kounis syndrome