Type I Kounis Syndrome after Protracted Anaphylaxis and Myocardial Bridge—Brief Literature Review and Case Report

Abstract

The term allergic angina, introduced for the first time by Nicholas Kounis in 1991, initially referred to the coexistence of acute coronary syndromes with allergy or hypersensitivity. At present, it is believed that Kounis syndrome is a particular case of systemic disease, with multiorgan arterial involvement generated during immediate hypersensitivity reactions. Myocardial bridging (MB), a condition that can induce coronary artery spasm, has long been regarded as a benign condition. Since both pathologies are associated with arterial spasm, Kounis syndrome and MB are considered to be confounding pathologies for acute coronary syndromes, and their association is quite a rare finding. To date, there are no precise data on the epidemiology, and the population affected by Kounis syndrome seems to be highly heterogeneous. Since this is a rare disease, even less is known about possible different phenotypes, including MB overlap. We report a case of type I variant Kounis syndrome associated with MB with no evidence of coronary artery disease, occurring as late presentation, following a severe systemic reaction (anaphylaxis) induced by a Hymenoptera sting. At present, only two other cases of type I and one case of type II Kounis syndrome occurring in patients with myocardial bridging have been described.

A Case of New Onset Iohexol Contrast Induced Kounis Syndrome after Prior Contrast Exposure

“…Iodine based Contrast Media (RCM) has been known to cause anaphylactic adverse effects and has at times led to death secondary to anaphylaxis [6]. The role of RCM has also been established as a cause of Kounis Syndrome [3]. He had previously been given the same contrast in different volumes and concentrations on three separate occasions with no adverse effects.…”

“…This is likely a new anaphylactic reaction caused by repeat exposure to RCM although there was a gap of 4 years between repeat exposures. Although developing an anaphylactic reaction due to repeat exposure to RCM is fairly common [3], it is worth noting that the association of Kounis syndrome and repeat exposure to RCM has not been determined. Prior case studies have not highlighted if the anaphylactic occurred after an initial exposure or repeat.…”

“…This results in coronary vasospasm and/or coronary plaque erosion or rupture [2]. The presentation is similar to that of an acute coronary event with chest pain and corresponding changes in EKG and troponin [3]. This was first reported in 1950 with a coronary event being attributed to an allergic reaction to Penicillin [4].…”