We present a case of a patient with no cardiac history presenting with a myocardial infarction following a wasp sting. Case: A 71-year-old male with no prior allergic history presented to the hospital following a wasp sting. [ahajournals.org]

At present, the pathogenesis of KS can be explained by the effects of mast-cell mediators on the heart. [hindawi.com]

Some unusual presentations include gastrointestinal symptoms such as loose stools and abdominal pain, but in rare cases, they may present as myocardial infarction. [joicc.org]

More recently, variant presentations of allergic angina have been described. [ncbi.nlm.nih.gov]

Case: A 61 year-old man presented to the emergency department after being swarmed by bees. He complained of diffuse pain, but denied cardiopulmonary symptoms. [onlinejacc.org]

• Chest Discomfort

  He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]

  A few minutes later, he regained consciousness but developed chest discomfort, with new-onset ST elevation in leads II, III, and aVF and ST depression in leads I, aVL, and V1 through V3 (Figure). [jamanetwork.com]

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  A few minutes after administration of the drug, the patient had sudden chest discomfort and pain in the left arm, shortness of breath, sweating and palpitations, generalized erythema and cutaneous rashes that justified admission to Emergency Room. [clinmedjournals.org]

  Treatment for anaphylaxis was initiated with intravenous hydrocortisone, diphenhydramine, and famotidine with improvement in pruritus, dyspnea, and chest discomfort. The patient's blood pressure also improved to 120/60 mm Hg. [ncbi.nlm.nih.gov]

• Malaise

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  The patient presents a coronary syndrome that can manifest as malaise with chest pain of anginal characteristics, and simultaneously also shows symptoms typical of an anaphylactic reaction: hypotension in the context of contact with a known allergen, [medintensiva.org]

  […] was 120/70mmHg, pulse rate was 80 beat per minute, and ECG revealed no abnormalities while the symptom had relieved. 24h Holter (Figs. 11, 12 and 13) revealed ST segment elevation for 2~3 mm in leads II, III, aVF, V5, V6 at 13:40-13:42 (when he felt malaise [bmccardiovascdisord.biomedcentral.com]

• Pallor

  […] symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis Hypotension Pallor [medscape.com]

  […] tissues, surrounding the coronary arteries.[5][6] Signs and symptoms[edit] Acute coronary syndrome (ACS) is usually associated with a constrictive pain in the chest, characteristically with radiation to the neck or the left arm and often associated with pallor [en.wikipedia.org]

• Dyspnea

  He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]

  Two hours later, he developed chest pain, dyspnea and diaphoresis. Repeat ECG revealed ST elevation in leads II, III, and aVF with reciprocal changes. He received aspirin and heparin and was taken for coronary angiography. [onlinejacc.org]

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  We present a case of a young woman who experienced attacks of dyspnea, hypoxemia, and hypotension during and after a spinal anesthesia with bupivacaine. [journals.lww.com]

  Treatment for anaphylaxis was initiated with intravenous hydrocortisone, diphenhydramine, and famotidine with improvement in pruritus, dyspnea, and chest discomfort. The patient's blood pressure also improved to 120/60 mm Hg. [ncbi.nlm.nih.gov]

• Vomiting

  […] words: Kounis syndrome, Coreopsis atramentaria, acute coronary syndrome Case report A 27-year-old man, with no cardiovascular risk factors and a history of mild persistent asthma, nasal polyps and aspirin allergy, was transferred with dizziness and vomiting [signavitae.com]

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  It can manifest with a constellation of symptoms, but common manifestations include urticaria, shortness of breath, vomiting, lightheadedness, and low blood pressure. [joicc.org]

  This condition can be accompanied by systemic manifestations such as abdominal pain, nausea, vomiting and diarrhea.[8] The humanized monoclonal IgG anti-IgE antibody omalizumab that binds specifically to circulating IgE molecules and interrupting the [jpharmacol.com]

  Due to his confusion upon admission, we could only take a detailed history one hour after the initial symptoms, revealing NSAID ingestion (75 mg of diclofenac) for shoulder pain ten minutes before the syncope accompanied by palmoplantar pruritus, vomiting [scielo.br]

• Nausea

  […] symptoms (rash, urticaria, angioedema), breathing (dyspnoea, wheezing, hoarseness, stridor) and/or gastrointestinal (abdominal pain, nausea, vomiting). [signavitae.com]

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  […] coronary arteries.[5][6] Signs and symptoms[edit] Acute coronary syndrome (ACS) is usually associated with a constrictive pain in the chest, characteristically with radiation to the neck or the left arm and often associated with pallor, sweatiness, nausea [en.wikipedia.org]

  This condition can be accompanied by systemic manifestations such as abdominal pain, nausea, vomiting and diarrhea.[8] The humanized monoclonal IgG anti-IgE antibody omalizumab that binds specifically to circulating IgE molecules and interrupting the [jpharmacol.com]

  CASE PRESENTATIONS Case 1 A 64-year-old man with known peripheral arterial disease, chronic obstructive pulmonary disease, coronary artery disease, dyslipidemia, and hypertension presented with pruritus, chest pain, dyspnea, and nausea immediately after [ncbi.nlm.nih.gov]

• Thrombosis

  Uniquely, in our patient in addition to acute coronary thrombosis his hospital course was also complicated by acute venous thrombosis and heparin induced thrombocytopenia which may suggest a disorder of inherent coagulopathy behind Kounis syndrome. [cdt.amegroups.com]

  Catecholamine increase in patients with angina renders blood platelets more sensitive and more prone to aggregation and thrombosis. Indeed, adrenaline administration has been shown to induce acute drug-eluting stent thrombosis [18]. [tmsforacure.org]

  Although the pathophysiology of thrombosis of drug-eluting stents is multifactorial, a recent review by Chen et al.2 states that Kounis syndrome can be one of the potential causes. [revespcardiol.org]

  Type III occurs in the setting of coronary thrombosis (including stent thrombosis) where aspirated thrombus stained with hematoxylin-eosin and Giemsa demonstrate the presence of eosinophils and mast cells respectively. [en.wikipedia.org]

• Chest Pain

  However, ischemic chest pain continued attacking in the morning during hospitalization. [bmccardiovascdisord.biomedcentral.com]

  However the subtle ST- changes and anginal chest pain prompted suspicion for acute coronary syndrome (ACS) then confirmed by a positive troponin. [ahajournals.org]

  Approximately 5 minutes after arrival to the hospital, he complained of chest pain, accompanied by nausea and diaphoresis. Urticarial skin lesions appeared, scattered on the trunk and extremities, and syncope ensued with loss of consciousness. [signavitae.com]

  The patient continued to have chest pain, and hence, a coronary angiogram was done. Left injection showed mid left anterior descending mild plaque; the patient started developing breathlessness with ST elevation in leads II, III, and aVF. [joicc.org]

  Two months later, the patient was again hospitalized with a second episode of syncope arrest and chest pain. In the brain magnetic resonance image, no significant focal intracranial abnormality was detected. [wjgnet.com]

• Hypotension

  Prolonged hypotension is another pathogenic mechanism for acute coronary syndrome, especially in patients with compromised cardiovascular system. [eusem.org]

  While still on the table in the electrophysiology lab, the patient developed hypotension and the monitor showed ST elevations in the inferior leads, as shown in Figure 1. [cureus.com]

  He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]

  Physical examination demonstrated a heart rate of 30 bpm and severe hypotension (60/40 mmHg). [signavitae.com]

  Five minutes after receiving a vial of intravenous metamizole, she started to show generalized urticaria, chest pain, and intense dyspnea, accompanied by severe hypotension (systolic blood pressure: 70mmHg). [revespcardiol.org]

• Tachycardia

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  Physical exam was significant for tachycardia, extensive envenomation and urticaria. Initial electrocardiogram (ECG) revealed no evidence of active ischemia. [onlinejacc.org]

  They also induce tachycardia, dysfunctional ventricular contractility and blockade of atrioventricular conduction. [eusem.org]

  The initial electrocardiogram showed sinus tachycardia at 120 bpm with ST elevation in the anterior leads. Treatment began with volume replacement, steroids, and intravenous antihistamines. [revespcardiol.org]

  […] leading to plaque rupture and initiation of inflammatory cascade leading to acute thrombus formation.[10] Clinically, anaphylactic reactions occur as a systemic phenomenon, leading to activation of mast cells dwelling in the cardiac tissue producing tachycardia [joicc.org]

• Palpitations

  We report the case of 57-year-old man, with hypertension and history of allergy, referred for facial rash and palpitations appeared after consumption of canned tuna fish. [tandfonline.com]

  Kounis syndrome Hypersensitivity myocarditis Cardiac symptoms Acute chest pain + - Chest discomfort + + Dyspnea + + Palpitations + + Sudden death + + Cardiac signs Elevated JVP + + Irregular pulse + + Gallop rhythm + + Electrocardiographic signs Atrioventricular [medscape.com]

  A few minutes after administration of the drug, the patient had sudden chest discomfort and pain in the left arm, shortness of breath, sweating and palpitations, generalized erythema and cutaneous rashes that justified admission to Emergency Room. [clinmedjournals.org]

  […] confusion upon admission, we could only take a detailed history one hour after the initial symptoms, revealing NSAID ingestion (75 mg of diclofenac) for shoulder pain ten minutes before the syncope accompanied by palmoplantar pruritus, vomiting, sweating, palpitations [scielo.br]

  Clinical effects usually occur within two hours of ethanol ingestion and include; headache, flushing of the face, neck, and trunk, Nausea and vomiting, tachycardia, palpitations, chest pain, dyspnea, marked apprehensiveness, rarely, hypotension, cardiac [signavitae.com]

• Pruritus

  He also reported numerous episodes of feeling faint, generalized flushing and skin pruritus that led to repeated assessments at the emergency department. [cmaj.ca]

  Treatment for anaphylaxis was initiated with intravenous hydrocortisone, diphenhydramine, and famotidine with improvement in pruritus, dyspnea, and chest discomfort. The patient's blood pressure also improved to 120/60 mm Hg. [ncbi.nlm.nih.gov]

  The most commonly reported adverse events were periorbital oedema (1,339), pruritus (1,223), orbital oedema (828), urticarial (594) and rash (532)7. [npra.gov.my]

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  […] food-dependent EIA cholinergic urticaria, exercise-induced bronchospasm, and rhinitis.[1] In a report,[2] the authors described a 26-year-old male with 3-year history of exercise-induced rash accompanied by flushing, feeling unwell and warm, eyelid angioedema, pruritus [jpharmacol.com]

• Sweating

  He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]

  Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis Hypotension Pallor Palpitations Skin rash Sudden death Sweating [medscape.com]

  After a serious attack of 15 minutes with heavy sweating at 2:00, she was sent to our hospital. On admission, her blood pressure was 150/100 mmHg, heart rate was 76 beat per minute, physical examination revealed no abnormalities. [bmccardiovascdisord.biomedcentral.com]

  A few minutes after administration of the drug, the patient had sudden chest discomfort and pain in the left arm, shortness of breath, sweating and palpitations, generalized erythema and cutaneous rashes that justified admission to Emergency Room. [clinmedjournals.org]

  This kind of urticaria has been attributed to water in sweat (aquagenic), during exercise, which reacts with sebum forming a compound acting as an allergen that induces the release of histamine. [jpharmacol.com]

• Skin Rash

  rash Sudden death Sweating Electrocardiographic signs Atrial fibrillation Bigeminal rhythm Nodal rhythm Sinus bradycardia Sinus tachycardia ST segment depression or elevation T-wave flattening and/or inversion QRS complex prolongation QT segment prolongation [medscape.com]

  He suffered skin allergy with flushing, itching, erythematous rashes and urticaria on the exact day taking the decoction and experienced several episodes of mild chest pain. [bmccardiovascdisord.biomedcentral.com]

• Headache

  Clinical symptoms Acute chest pain Chest discomfort Difficulty in swallowing Dyspnea Faintness Headache Malaise Nausea Pruritus Syncope Vomiting Urticaria Clinical signs Bradycardia or tachycardia Cardiorespiratory arrest Cold extremities Diaphoresis [medscape.com]

  […] cholinergic urticaria, exercise-induced bronchospasm, and rhinitis.[1] In a report,[2] the authors described a 26-year-old male with 3-year history of exercise-induced rash accompanied by flushing, feeling unwell and warm, eyelid angioedema, pruritus, and headache [jpharmacol.com]

  Clinical effects usually occur within two hours of ethanol ingestion and include; headache, flushing of the face, neck, and trunk, Nausea and vomiting, tachycardia, palpitations, chest pain, dyspnea, marked apprehensiveness, rarely, hypotension, cardiac [signavitae.com]

A workup for allergic acute coronary syndrome was done. Tryptase levels were raised, and total IGE was 1167.5 IU/ml. She improved symptomatically, and there was complete ST resolution by day 3. [joicc.org]

Allergological workup is essential for an accurate diagnosis and to explore cross-reactivity between cefazolin and other beta-lactams. [karger.com]

• Ventricular Bigeminy

  bigeminy and nonsustained ventricular tachycardia at 13:20 and 13:42. [bmccardiovascdisord.biomedcentral.com]

• Polyps

  The histopathological examination of polyps was suggestive of inflammatory nasal polyps. An immunoglobulin E level was 396 kU/L (reference range: 20-100 kU/L). Normal range for all allergens is less than 0.35 U/L. [wjgnet.com]

  The patient had a previous recognized history of mild persistent asthma, nasal polyps and aspirin allergy consistent with the Samter’s triad (asthma, aspirin sensitivity, and nasal polyps). The term Samter’s triad has become popular. [signavitae.com]

In addition to treatment of ACS, attention must also be given to treatment of the underlying allergic process. [onlinejacc.org]

We entirely agree with the authors of this report1 that there is no consensus on treatment for Kounis syndrome, and most of the data on it are from case reports. [revportcardiol.org]

Treatment of Kounis syndrome.. Int J Cardiol., 143 (2010), pp. 223-226 [revespcardiol.org]

She was treated for anaphylactic shock with an infusion of epinephrine as the mainstay of anaphylaxis treatment. [journals.lww.com]

[…] they are unable to substitute in the treatment of anaphylaxis. [medintensiva.org]

Early recognition and intervention have a great effect on prognosis. [ncbi.nlm.nih.gov]

Some cases may require immune suppressors.Prognosis Although some studies have found the prognosis to be better in type I KS, in both types the prognosis depends on the magnitude of the initial allergic reaction, the patient sensitivity, comorbidity, [medintensiva.org]

The prognosis of Kounis syndrome is generally good, although complications such as pulmonary edema, arrhythmia and thrombus have been reported during the acute phase. [revespcardiol.org]

The usual prognosis of a patient with Kounis syndrome is nonfatal, but in our case, the patient had multiple episodes of cardiac arrhythmias and ventilator-associated pneumonia, factors that worsened the scenario. [journals.lww.com]

Beyond the acute episode, prognosis of KS is good in the majority of cases, with left ventricular function normalizing in a matter of weeks. Mortality rate is unknown, essentially due to shock, pulmonary edema, and arrhythmias [4]. [hindawi.com]

Etiology of Kounis Syndrome A variety of drugs, environmental exposures, foods, and other conditions are the main triggers of Kounis syndrome (Table 1). [tmsforacure.org]

[…] rupture manifesting as acute myocardial infarction Clinical implications It has been shown that the same mediators, released during acute allergicepisodes, are increased in blood or urine of patients suffering from acute coronary syndromes of nonallergic etiology [dictionnaire.sensagent.leparisien.fr]

Kounis syndrome has revealed that the same mediators released from the same inflammatory cells are present in acute coronary events of nonallergic etiology. [futuremedicine.com]

Combined etiology of anaphylactic cardiogenic shock: amiodarone, epinephrine, cardioverter defibrillator, left ventricular assist devices and the Kounis syndrome. Ann Card Anaesth 2015;18(2):261-264. DOI:10.4103/0971-9784.154498 [ Links ] [scielo.org.za]

Many etiologies have been reported[1,2], including drugs (antibiotics, analgesics, antineoplastics, contrast media, corticosteroids, intravenous anesthetics, non-steroidal anti-inflammatory drugs, skin disinfectants, thrombolytics, anticoagulants), various [wjgnet.com]

Epidemiology of acute coronary syndrome co-existent with allergic/hypersensitivity/anaphylactic reactions (Kounis syndrome) in the United States: A nationwide inpatient analysis [published online June 8, 2019]. [pulmonologyadvisor.com]

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. [ajp.paramedics.org]

Kounis NG: Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med 2016; 54: 1545–1559. [karger.com]

"Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management" (PDF). Clinical Chemistry and Laboratory Medicine. 54 (10): 1545–59. doi:10.1515/cclm-2016-0010. [en.wikipedia.org]

References Kounis NG: Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. [cureus.com]

Inflammatory mediators such as histamine constitute the pathophysiologic basis of Kounis hypersensitivity-associated acute coronary syndrome. [tandfonline.com]

Some authors have argued against the vasospastic process being the dominant underlying pathophysiological explanation for KS. [ncbi.nlm.nih.gov]

Its etiology, pathophysiology, and treatment have yet to be determined. The incidence is 2.1% of female patients and 0.5% of all patients with ST-elevation myocardial infarction. [tmsforacure.org]

The main pathophysiological mechanism is vasospasm of the epicardial coronary arteries because of increased inflammatory mediators that are released during a hypersensitivity reaction. [journals.lww.com]

Atopic individuals are specifically prone to this condition.[4] Therefore, this report raises several important questions concerning the etiology, pathophysiology, associations and treatment of EIA. [jpharmacol.com]

However, these authors did not elaborate in the mechanism of action of glucocorticoids in preventing the recurrent and permanent AF. [academic.oup.com]

Once the allergic component is identified, desensitization measures should be employed if possible to prevent such events in the future. [cdt.amegroups.com]

Some of the causes of Kounis syndrome are climate and environmental conditions, pollen cross-reactivities, hymenoptera exposures, overconsumption of medicines, inadequacy of preventative measures, and gene–environment interactions starting in early life [tmsforacure.org]

H1 blockers are advised in KS (dexchlorpheniramine 5mg, up to a total of 18mg a day).H2 blockers H2 blockers can prevent gastrointestinal bleeding. [medintensiva.org]

Protection of the cardiac tissue and the emergency treatment of the acute ischemic episode should be combined with the identification and treatment of the allergic sensitization, the cause of anaphylaxis, to prevent further episodes. [hindawi.com]