Presentation
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]
Presentation as cardiogenic shock is extremely rare and only 1 similar case report has been published previously.5 There are no clinical guidelines for treating Kounis syndrome at present. [revespcardiol.org]
Entire Body System
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Chest Discomfort
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]
He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]
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 block Left bundle [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]
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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]
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Hypoxemia
with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips-tongue-uvula) AND AT LEAST ONE OF THE FOLLOWING: A) Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia [ekjm.org]
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]
Fentanyl and its derivatives show only limited mast cell activation and may be the option of choice when opiates are required.Oxygen Oxygen should be administered to patients with ACS in the presence of saturation values of under 90%, or a risk of hypoxemia [medintensiva.org]
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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]
Respiratoric
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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]
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 block Left bundle [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]
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Stridor
[…] after exposure to a likely allergen for that patient (minutes to several hours) A) Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula) B) Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor [ekjm.org]
[…] pain, nausea and diaphoresis and simultaneously typical symptoms of an anaphylactic reactions in the context of contact with known allergens including hypotension, skin symptoms (rash, urticaria, angioedema), breathing (dyspnoea, wheezing, hoarseness, stridor [signavitae.com]
[…] characteristics, and simultaneously also shows symptoms typical of an anaphylactic reaction: hypotension in the context of contact with a known allergen, skin manifestations (rash, urticaria, angioedema), respiratory alterations (dyspnea, wheezing, dysphonia, stridor [medintensiva.org]
Gastrointestinal
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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]
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]
Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) C) Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence) D) Persistant gastrointestinal symptoms (eg, crampy abdominal pain, vomiting [ekjm.org]
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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]
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]
[…] of an anaphylactic reaction: hypotension in the context of contact with a known allergen, skin manifestations (rash, urticaria, angioedema), respiratory alterations (dyspnea, wheezing, dysphonia, stridor) and/or digestive disorders (abdominal pain, nausea [medintensiva.org]
Cardiovascular
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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]
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]
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]
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]
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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]
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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]
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]
He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]
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Tachycardia
ST segment elevation ST segment depression T-wave inversion Ventricular tachycardia Laboratory signs Coronary angiography /- - Eosinophilia /- /- Increased cardiac enzymes and especially CPK-MB Increased troponins Cardiomegaly in the chest X-ray /- / [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]
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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 block Left bundle [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]
Skin
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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]
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]
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Sweating
He developed constricting chest discomfort associated with dyspnea, sweating and hypotension. [revportcardiol.org]
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]
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]
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]
[…] 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, sweating [scielo.br]
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Skin Rash
[…] 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 Palpitations Skin [medscape.com]
He is a smoker with no other cardiac risk factors and no history of CVD, he was allergic to pineapple before but only manifested as slight itching and skin rashes which spontaneously disappeared in hours. [bmccardiovascdisord.biomedcentral.com]
Urogenital
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Incontinence
[…] tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula) B) Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) C) Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence [ekjm.org]
Neurologic
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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]
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]
Workup
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]
Microbiology
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Helicobacter Pylori
pylori infection in patients treated with non-steroidal anti-inflammatory drugs 2008 November;75(5) [ekjm.org]
Rhythm
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Ventricular Bigeminy
Fig. 11 ST segment elevation for 2-3 mm in leads II, III, aVF, V5, V6 at13:40-13:42 in Holter Fig. 12 Nonsustained ventricular tachycardia at 13:42 in Holter Fig. 13 Ventricular bigeminy at 13:40 in Holter Discussion We report 5 rare cases of KS induced [bmccardiovascdisord.biomedcentral.com]
Treatment
In addition to treatment of ACS, attention must also be given to treatment of the underlying allergic process. [onlinejacc.org]
Treatment of Kounis syndrome.. Int J Cardiol., 143 (2010), pp. 223-226 [revespcardiol.org]
[…] they are unable to substitute in the treatment of anaphylaxis. [medintensiva.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]
She was treated for anaphylactic shock with an infusion of epinephrine as the mainstay of anaphylaxis treatment. [journals.lww.com]
Prognosis
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
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]
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]
Conversely, serum levels of tryptase should be measured in all patients with acute coronary syndrome in order to reveal a possible allergic etiology. This is particularly important in the absence of coronary obstruction on angiography. [hindawi.com]
Epidemiology
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 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. 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 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]
Pathophysiology
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]
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]
Prevention
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]