Case Report: Perioperative Kounis Syndrome in an Adolescent With Congenital Glaucoma

Abstract

A 12-year-old male patient suffering from congenital glaucoma developed bradycardia, left ventricular failure, and hypotension after induction of anesthesia. Electrocardiography and echocardiography revealed a complete normalization of ECG and a complete spontaneous recovery in the cardiac function 72 hours from the beginning of the clinical manifestations, while cardiac Magnetic Resonance Imaging was performed, and coronary Computed Tomography scan revealed a myocardial bridge of a tract of the left anterior descendent coronary artery. Diagnosis of Kounis syndrome (KS) was made, a relatively novel, under-recognized clinical condition, defined as the manifestation of an acute coronary syndrome accompanied by mast cell activation and platelet aggregation involving interrelated and interacting inflammatory cells in the setting of allergic, hypersensitivity, anaphylactic or anaphylactoid insults. We described one of the first pediatric cases of KS related to anesthetic medications. In children, this syndrome has been only described in isolated case reports or small case series. Thus, it appears critical to report new cases of KS in children to increase the awareness of this disease in pediatric healthcare workers so as to enhance its early recognition and optimal therapeutic strategy. Furthermore, it appears of paramount importance the implementation of universal guidelines accepted by allergology and cardiology societies, in order to standardize the management of pediatric and adult patients with KS. Finally, a close collaboration between pediatric allergists and cardiologists seems fundamental for an optimal multidisciplinary patient care.

Exploring Variations in Etiology and Clinical Presentations of Kounis Syndrome Across Pediatric and Adult Populations: A Comprehensive Review

“…In the adult case reports, antibiotics such as vancomycin, cephalosporins, amoxicillin and clavulanic acid, clarithromycin, sulbactam-ampicillin, gemifloxacin, and penicillin were among the common antibiotics that lead to Kounis syndrome [7]. Atropine, epinephrine, midazolam, rocuronium, and tramadol were also reported as other drugs that led to Kounis syndrome in the pediatric case reports [10][11][12][13][14]. Across the 330 case reports that we finalized on Kounis syndrome in the adult population, a variety of drugs were the causative agents of Kounis syndrome, including NSAIDs, immunosuppressants, neuromuscular blocking agents, antipsychotics, and inhaled anesthetics (see Table 2).…”

“…50% of patients in the pediatric case reports related to Kounis syndrome presented with EF>50% [ 6 - 8 , 10 , 13 , 67 - 69 , 83 , 91 ]. Despite some pediatric patients presenting with EF<50%, most patients had EF>50% at discharge [ 11 - 12 , 14 , 16 - 17 ]. Hypokinesia was also a common finding on echocardiography in the pediatric population [ 6 , 9 , 19 , 68 ].…”