Kounis syndrome is an underdiagnosed medical condition and represents acute coronary syndrome in the setting of allergic reaction. With the increasing prevalence of allergic reactions, more cases of Kounis syndrome are being reported in the literature. Recognizing patients with acute coronary syndrome during an episode of anaphylaxis may be difficult due to symptom overlap; hence, a high index of suspicion must be maintained. This is vital as the management of Kounis syndrome requires meticulous use of medications as some pharmacological agents beneficial to acute coronary syndrome may be detrimental for the ongoing anaphylaxis and vice versa. We report a case of type 2 variant of Kounis syndrome following severe anaphylaxis to nuts to highlight the need for clinicians to suspect Kounis syndrome when managing patients with anaphylaxis and chest symptoms.

Malignant nodular hidradenoma, also known as Malignant Hidradenocarcinoma (MHA), is a rare tumor of sweat glands that accounts for less than 0.001% of all tumors [1-3,14]. Although it typically arises de-novo, MHA rarely progresses from hidradenitis suppurativa (HS), a disorder of apocrine glands characterized by chronic inflammation [5,6,9]. HS is due to recurrent follicular occlusion leading to painful debilitating cutaneous/subcutaneous abscesses requiring drainage [5,6,9]. Common sites include axillary, anogenital and inguinal regions [5,6,9]. The worldwide prevalence of HS is 1%-4% [5,6]. Incidence of all eccrine carcinomas is ~ 6% [14]. Risk-factors include family history, obesity, and smoking [5,6,9]. Severe complications associated with HS are squamous cell carcinoma and adenocarcinoma [2,6]. MHA progression is extremely aggressive with 60% cases having metastatic spread within the first 2 years of diagnosis [14].