An Insight into Kounis Syndrome: Bridging Clinical Knowledge with Forensic Perspectives

Abstract

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or hypersensitivity reactions. Incidence rates vary, with studies reporting 19.4 per 100.000 among all admissions and 3.4% among allergy patients. This review explores the expanding understanding of KS, encompassing various manifestations, and focusing on both clinical data and forensic findings useful in performing a diagnosis. The pathophysiology of this syndrome involves a complex interplay between allergic reactions and the cardiovascular system. Mast cell activation, histamine release, leukotrienes, cytokines, and platelet activation can contribute to coronary events. Three types of classification systems (allergic angina, allergic myocardial infarction, allergic stent thrombosis) aid in categorizing presentations. The diagnosis of KS relies on clinical presentation, laboratory findings, and imaging. Postmortem assessment of KS is based on the integration of circumstantial data, autopsy, and histological findings. Biochemical and immunohistochemical analyses also contribute to postmortem diagnosis. In conclusion, a combined, multidisciplinary approach should be used to ease the diagnostic process, which is crucial for forensic practitioners in confirming KS occurrence.

Arrhythmogenic Right Ventricular Cardiomyopathy Post-Mortem Assessment: A Systematic Review

“…According to the American College of Medical Genetics and Genomics and the Association for Molecular Pathology guidelines, each mutation found after performing genetic tests should be distinguished as pathogenic, likely pathogenic, of uncertain significance (VUS), probably benign or benign [ 67 ]. Because of the continuous increase in the number of variants described in the literature, performing a post-mortem genetic analysis is of fundamental importance to correctly identify the cause of death in all the cases of ARVC without any evident cardiac structural alterations [ 68 , 69 , 70 ].…”

Fatal Outcome Due to Kounis Syndrome Following Fluorescein Retinal Angiography: A Case Report

“…Therefore, other analyses have been performed. In particular, both immunohistochemistry and biochemistry have been proved to be very useful [ 8 ].…”

“…Thus, to support the occurrence of anaphylaxis, several studies have been reported in the literature, proposing an analysis of different immunohistochemical markers for the activated mast cell detection. Among these suggested markers, both the anti-stem cell factor (which detects the mature forms of mast cells) and anti-CD117 (identifying tissue mast cells) are considered to be useful [ 8 , 19 ].…”

“…In a clinical setting, just as for acute coronary syndromes, for the diagnosis of Kounis syndrome the biochemical analysis of myocardial necrosis markers has a pivotal role [ 36 ]. Thus, the measurement of troponin in a forensic setting provides useful evidence supporting the diagnosis of Kounis syndrome [ 8 ]. Moreover, the cardiac involvement can be evaluated using p-BNP as an indicator of myocardial disfunction [ 37 ].…”

“…Thus, the diagnosis must be performed by the integration of several findings emerging from different types of investigations, among which biochemistry and immunohistochemistry are considered the most useful [ 7 ]. This post mortem approach is crucial also in cases with suspicion of KS, in which particular attention should also be given to the heart and coronary arteries [ 8 ].…”