Kounis syndrome – a silent killer under the blanket

Abstract

Allergy angina syndrome or allergic myocardial infarction is an immune-mediated coronary spasm which is also known as Kounis syndrome (KS). It's not uncommon, but it's often underdiagnosed. In a typical case of allergy, a skin reaction may be preceding symptoms and shock status may be a severe accompanying symptom. KS may cause devastating events namely cardiac arrest in some extreme cases. A 40-year-old obese gentleman with underlying intrapapillary mucinous neoplasm of uncinate process of pancreas was electively admitted for pancreaticoduodenectomy. He had a past medical history of hypertension and chronic gout arthritis with no previous history of ischemic heart disease. Intraoperatively was uneventful and he was monitored in the intensive care unit postoperatively. However, due to new onset obstructive jaundice postoperatively, he was subjected to contrast-enhanced computed tomography (CECT) of the abdomen for further evaluation. Following injection of contrast, he was developed generalized skin rashes followed by respiratory distress and cardiac arrest. Intravenous steroid and antihistamine were given immediately. He was resuscitated for 9 min, and ECG post-resuscitation showed new onset ST segment elevation V3-V6. Bedside echocardiography revealed preserved ejection function with no obvious hypokinetic segment. Repeated ECG two hours later noted resolution of the ST elevation with the absence of Q wave, T wave inversion, and return into sinus rhythm. Unfortunately, he was complicated prolonged hospital stay, seizure, hypoxic-ischemic encephalopathy (HIE), persistent abdominal sepsis subsequently succumbed after 27 days of admission. As per the above case, cardiac arrest following contrast agent administered should ring a bell about Kaonis syndrome. Diagnosis made needs the concurrent presence of acute coronary syndrome and an allergic event. Every contrast agent has the potential to cause KS. Therefore it is very crucial to detect and treat promptly as it may also lead to death.