Kounis syndrome: Optical coherence tomography findings

Abstract

A 59-year-old man, smoker and with a past history of hypertension, was admitted to the emergency department because of a generalized erythema and hypotension after taking an oral dose of amoxicillin/clavulanic acid for a toe cellulitis. At first medical contact, the patient presented with hypotension (70/40 mm Hg), excessive sweating and a striking rash with urticaria on this back. The electrocardiogram showed ST-segment depression in leads III, aVF and V3–V6. After saline and aspirin administration the symptomatology was gradually relieved and the ST-segment changes normalized. A mild elevation of myocardial necrosis markers (maximum high-sensitivity cardiac troponin 169 ng/L) was detected. Urgent coronary angiography demonstrated a normal left coronary artery and a severe hazy lesion in the proximal segment of the right coronary artery that persisted after nitroglycerine administration (Fig. 1A ). Embolization of a small distal branch was also noticed. Optical coherence tomography (OCT) disclosed a thin-cap fibroatheroma with a clear fibrous-cap rupture and a deep cavity (Fig. 2A ). A large intracoronary thrombus was also detected (Fig. 2B–C). A bare metal stent was implanted successfully (Fig. 1B–C). The patient was discharged three days later with the diagnosis of variant II Kounis syndrome and at three months of follow-up he remains asymptomatic.