Kounis syndrome is an uncommon clinical presentation of acute coronary syndrome secondary to an allergic or hypersensitivity reaction, especially anaphylaxis. It results when inflammatory mediators are released following mast cell activation, some of these mediators cause coronary artery vasospasm and may initiate thrombus formation in susceptible individuals. Although Kounis syndrome is becoming more widely known, many clinicians are still unaware of its existence. We present a case report and a literature review of the pre-hospital treatment of Kounis syndrome by emergency medical services.
A literature search of the EMBASE, MEDLINE and PubMed electronic medical databases was conducted using the terms ‘Kounis syndrome’, ‘allergic acute coronary syndrome’ and ‘allergic myocardial infarction’. The purpose of the literature search was to identify the pre-hospital treatment of Kounis syndrome by emergency medical services. We included case reports of Kounis syndrome that described the medical treatment provided by emergency medical services, published any time up to October, 2017.
Anaphylaxis is the most commonly treated component of Kounis syndrome by emergency medical services (66% of reported cases). Both components of Kounis syndrome, anaphylaxis and acute coronary syndrome, were treated in 16% of reported cases. No specific treatment was provided for either component of Kounis syndrome in 16% of reported cases.
The pre-hospital treatment of Kounis syndrome by emergency medical services is infrequently reported in the literature. Kounis syndrome involves two distinct clinical conditions, both of which should be considered during treatment.
Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the concept of allergic angina. Br J Clin Pract 1991;45:121–8.
Pfister CW, Plice SG. Acute myocardial infarction during a prolonged allergic reaction to penicillin. Am Heart J 1950;40:945–7.
Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med 2016;54:1545–59.
Biteker M. Current understanding of Kounis syndrome. Expert Rev Clin Immunol 2010;6:777–88.
Antonelli D, Rozner E, Turgeman Y. Kounis syndrome: acute ST segment elevation myocardial infarction following allergic reaction to amoxicillin. Isr Med Assoc J 2017;19:59–60.
De Groot J, Gosselink A, Ottervanger J. Acute ST-segment elevation myocardial infarction associated with diclofenac-induced anaphylaxis: case report. Am J Crit Care 2009;18:388–6.
Gosselin RJ, Gross IS. Abstracts from the 38th Annual Meeting of the Society of General Internal Medicine (from sting to STEMI: mechanisms and manifestations of Kounis syndrome). J Gen Intern Med 2015;30(Suppl 2):45–551.
Ihdayhid AR, Rankin J. Kounis syndrome with Samter–Beer triad treated with intracoronary adrenaline. Catheter Cardiovasc Interv 2015;86:E263–7.
Licitra G, Luis M, Meniz Y, et al. Poster Session TPS (1378 Kounis syndrome: an underdiagnosed entity). Allergy 2017;72:383–757.
Memon S, Chhabra L, Masrur S, Parker MW. Allergic acute coronary syndrome (Kounis syndrome). Proc (Bayl Univ Med Cent) 2015;28:358.
Mirijello A, Pepe G, Zampiello P, et al. A male patient with syncope, anaphylaxis, and ST-elevation: hepatic and cardiac echinococcosis presenting with Kounis syndrome. J Emerg Med 2016;51:e73–7.
Nittner-Marszalska M, Kopeć A, Biegus M, et al. Non-ST segment elevation myocardial infarction after multiple bee stings. A case of “delayed” Kounis II syndrome? Int J Cardiol 2013;166:e62–5.
Regis AC, Germann CA, Crowell JG. Myocardial Infarction in the setting of anaphylaxis to celecoxib: a case of Kounis syndrome. J Emerg Med 2015;49:e39–43.
Rekik S, Andrieu S, Aboukhoudir F, et al. ST elevation myocardial infarction with no structural lesions after a wasp sting. ibid. 2012;42:e73–5.
Scherbak D, Lazkani M, Sparacino N, Loli A. Kounis syndrome: a stinging case of ST-elevation myocardial infarction. Heart Lung Circ 2015;24:e48–50.
Wada T, Abe M, Yagi N, et al. Coronary vasospasm secondary to allergic reaction following food ingestion: a case of type I variant Kounis syndrome. Heart Vessels 2010;25:263–6.
Simons FER, Ardusso LR, Bilo MB, et al. 2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol 2012;12:389–99.
Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation 2012;126:2020–35.
Akoz A, Tanboga HI, Emet M, et al. A prospective study of Kounis syndrome: clinical experience and cardiac magnetic resonance imaging findings for 21 patients. Acta Med Mediterraea 2013;9:811–6.
Yanagawa Y, Kondo A, Ishikawa K, et al. Kounis syndrome should be excluded when physicians treat patients with anaphylaxis. Ann Allergy Asthma Immunol 2017;119:392.
Lippi G, Buonocore R, Schirosa F, Cervellin G. Cardiac troponin I is increased in patients admitted to the emergency department with severe allergic reactions. A case-control study. Int J Cardiol 2015;194:68–9.
Cha YS, Kim H, Bang MH, et al. Evaluation of myocardial injury through serum troponin I and echocardiography in anaphylaxis. Am J Emerg Med 2015;34:140–4.
Abdelghany M, Subedi R, Shah S, Kozman H. Kounis syndrome: a review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome. Int J Cardiol 2017;232(Suppl C):1–4.
Jang WJ, Yang JH, Song YB, et al. Clinical Significance of postinfarct fever in st‐segment elevation myocardial infarction: a cardiac magnetic resonance imaging study. J Am Heart Assoc 2017;6(4).
Khan BQ, Kemp SF. Pathophysiology of anaphylaxis. Curr Opin Allergy Clin Immunol 2011;11:319–25.
Metcalfe DD, Baram D, Mekori YA. Mast cells. Physiol Rev 1997;77:1033–79.
Lanza GA, Careri G, Crea F. Mechanisms of coronary artery spasm. Circulation 2011;124:1774–82.
Laine P, Kaartinen M, Penttilä A, et al. Association between myocardial infarction and the mast cells in the adventitia of the infarct-related coronary artery. ibid. 1999;99:361–9.
Krishnaswamy G, Kelley J, Johnson D, et al. The human mast cell: functions in physiology and disease. Front Biosci 2001;6:D1109–27.
Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005;352:1685–95.
Libby P. Mechanisms of acute coronary syndromes and their implications for therapy. ibid. 2013;368:2004–13.
Kovanen PT, Kaartinen M, Paavonen T. Infiltrates of activated mast cells at the site of coronary atheromatous erosion or rupture in myocardial infarction. Circulation 1995;92:1084–8.
Deliargyris EN, Upadhya B, Sane DC, et al. Mast cell tryptase: a new biomarker in patients with stable coronary artery disease. Atherosclerosis 2005;178:381–6.
Xiang M, Sun J, Lin Y, et al. Usefulness of serum tryptase level as an independent biomarker for coronary plaque instability in a Chinese population. ibid. 2011;215:494–9.
Morici N, Farioli L, Losappio LM, et al. Mast cells and acute coronary syndromes: relationship between serum tryptase, clinical outcome and severity of coronary artery disease. Open Heart 2016;3:e000472.
Fassio F, Losappio L, Antolin-Amerigo D, et al. Kounis syndrome: a concise review with focus on management. Eur J Intern Med 2016;30:7–10.
Simons FER, Ardusso LR, Bilò MB, et al. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J 2011;4:1.