An unusual etiology of Kounis syndrome; warble fly

Abstract

Dear Editor We would like to report a case of Kounis syndrome which we diagnosed recently. Kounis syndrome is defined as the coexistence of acute coronary syndrome with allergic reaction.1 Kounis and Zavras described the condition as allergic angina syndrome on 1991.1 Braunwald suggested that histamines and leukotriens may cause coronary spasm.2 Drugs (eg: antibiotics, analgesics, contrast agents etc.), foods, bee sting and latex exposure are among the pathogenic insults.3–5 Three types have been described for now. In type 1 Kounis syndrome, patients have normal coronary arteries and they have no coronary risk factors. In type 2, there is underlying coronary artery disease. In type 3, stent thrombosis is the main pathologic condition. In this report we presented a patient who developed type 2 Kounis syndrome after warble fly bite (Hypoderma lineatum).6 Fifty-nine years old patient developed dyspnea, nausea and chest pain after warble fly (H. lineatum) bite. He was admitted to another center with these complaints. By the diagnosis of allergic reaction intravenous steroid and antihistaminic treatment were given to patient. Although the dyspnea was diminished after treatment, chest pain persisted. The ECG revealed ST segment elevation in anterior leads. The patient was referred to our clinic with diagnosis of acute anterior myocardial infarction. After admission of patient, coronary angiography was performed which demonstrated critical lesion at left anterior descending artery (Fig. 1). Successful stent deployment was performed with TIMI 3 antegrade flow. There was no any problem on first month visit. Fig. 1 Left coronary system of the patient during coronary angiography. Etiology of Kounis syndrome involves many pathogenic insults and we presented an unusual case of Kounis syndrome due to warble fly (H. lineatum) bite. Warble flies generally live on cattles as a parasite and thus they are generally seen in rural areas. Beside showing warble fly as pathogenic insult in Kounis syndrome, this case is also important to emphasize the importance of an ECG in a patient with allergic symptoms, especially in whom anginal symptoms are present.