Allergy Induced Acute Coronary Syndrome - Kounis Syndrome: Case Report. Poster used in CMC MAC 2021. OBJECTIVE: To discuss a rare occurrence of allergic reaction to NSAID causing Myocardial Infarction. BACKGROUND: A 21-year-old obese female with no other comorbidities was referred to us with history of chest pain, generalized urticarial rashes and itch suddenly following Inj.IM Diclofenac, which was given for heel pain relief. She was hemodynamically stable, but tachypneic, orthopneic and was having bilateral basal crepitations. ECG revealed significant ST depression & T inversion in II,III,aVF and V2-V6 and ST elevation in aVR. CXR showed pulmonary edema. Diagnosed as ACS following anaphylaxis and loading dose was given along with IM adrenaline, antihistamines, and steroids. Echo revealed global hypokinesia of LV. Cardiac enzymes were elevated. Meanwhile, she had a prompt relief of chestpain, but dyspnea worsened and warranted NIV support. Repeat ECG revealed regression of ST changes correlating with chest pain relief. After 2 days of NIV, patient’s dyspnea improved and weaned from NIV. CAG revealed normal epicardial coronaries. Serial cardiac enzyme levels showed falling trend and ECG was completely normal with no significant ST-T changes. Pre-discharge, repeat echo showed persistence of global hypokinesia. 2weeks later, repeat echo showed dramatic improvement with normal LV systolic function suggesting recovery from myocardial stunning. RESULTS: This qualifies for the diagnosis of MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries). In the setting of allergic trigger, vasospasm or coronary hypersensitivity is the underlying mechanism- described as KOUNIS SYNDROME. CONCLUSION: ECG changes and chest discomforts that occur in allergic reactions are not always secondary to distributive/anaphylactic shock. Sometimes heart could be the primarily affected organ by the allergic reaction as in this case. Although <200cases reported globally until 2017, it’s suspected to be frequently overlooked, hence likely to be more prevalent.

1. Dr. Manievelraaman Kannan, Junior Resident, Institute of Internal Medicine,
Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai – 03.
CLINICAL PRESENTATION
INVESTIGATIONS
CONCLUSION
DIAGNOSIS & MANAGEMENT
REFERENCES
Figure 1. ECG on arrival showing ST depression and T inversion in II, III,
aVF and V2-V6
INTRODUCTION
CONTACT
KOUNIS SYNDROME
Allergy induced Myocardial Infarction – Kounis Syndrome
Email: drmvraaman1994@outlook.com
Phone: 9789999778
This qualifies for the diagnosis of MINOCA (Myocardial
Infarction with No Obstructive Coronary Arteries). In the
setting of allergic trigger, vasospasm or coronary
hypersensitivity is the underlying mechanism -
described as KOUNIS SYNDROME. Since CAG is
normal in this case, therapy is limited to antihistamines,
steroids and vasodilators and patient had a complete
recovery.
CBC, RFT, LFT, Electrolytes – Normal
Cardiac enzymes (CK,CK-MB): Serially elevated
ECG on arrival: ST depression and T inversion in lead II, III,
aVF and V2 – V6 and ST elevation in aVR – localising to
Left Main territory
Echo: Global hypokinesia of LV; IVC:2 cm
ECG after 2 hours: Regression of ST-T changes –
correlating with chest pain relief
Echo on day 2: Persistence of global hypokinesia of LV
CAG – Normal Epicardial coronaries
On reviewing after 2 weeks:
ECG – Complete normalisation of previous ST-T changes
Echo – Normal LV systolic function – dramatic
improvement probably suggesting recovery from
myocardial stunning.
The primary goal of reporting this case is to highlight that the
ECG changes and chest discomforts that occur in
allergic reactions are NOT ALWAYS SECONDARY to
distributive / anaphylactic shock. Sometimes heart
could be the primarily affected organ by the allergic
reaction and subsequently causing systolic dysfunction
and cardiogenic shock. It is frequently overlooked and
its timely recognition is the key to better outcomes.
A 21-year-old female has developed complaints of chest
pain, generalised urticarial rashes and itch suddenly
following Inj. IM Diclofenac, which was given in a nursing
home for her heel pain relief. Patient diagnosed to have
anaphylaxis and IM adrenaline and 1L IV fluid bolus given.
Her symptoms persisted, hence referred to us. She has no
co-morbidities and has no past medical records.
On examination, she was conscious, oriented, tachypneic,
orthopneic. JVP was elevated. BP:100/70 mm Hg, PR:
96/min, RR: 28/min, SpO2: 90%.
CVS —S1 S2 +, RS – Bilateral basal crepitations +
ECG revealed ST-T changes compliant with diagnosis of MI.
The following investigations were done and patient treated
with loading dose of anti-platelets along with
antihistamines, steroids, vasodilators. After a while, patient
had a pain relief correlating with regression of ST-T
changes in ECG. But, dyspnea worsened over the day and
warranted NIV support for one day, after which patient
weaned off ventilator, underwent coronary angiogram
(CAG) and then discharged and advised to review after 2
weeks.
1. https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-017-0670-7
2. https://www.uptodate.com/contents/clinical-syndromes-of-stunned-or-hibernating-
myocardium
3. https://www.clinicaltherapeutics.com/article/S0149-2918(13)00078-7/fulltext
4. https://www.uptodate.com/contents/vasospastic-
angina?topicRef=89348&source=related_link
5. https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-018-0781-9
6. https://www.researchgate.net/publication/21361659_Histamine-
induced_coronary_artery_spasm_The_concept_of_allergic_angina
7. Int J Cardiol. doi:10.1016/j.ijcard.2019.06.002
8. https://www.internationaljournalofcardiology.com/article/S0167-5273(05)01050-8
/abstract
Acute coronary syndrome (ACS) is one
of the common disease presentations
encountered in medical practice.
Allergic reaction to drugs is also a
common occurrence and it manifests
with wide range of symptoms and
signs.
However, an allergic reaction triggering
ACS is a very rare occurrence and is
described in literature as Kounis
Syndrome (KS).
This is the case report of one such
occurrence where NSAID injection has
caused ACS in an otherwise healthy
person.
Graph 1. Trend of cardiac enzyme levels
Figure 2. ECG taken after 2 hours of arrival showing regression of ST-T changes
Figure 3. CT Chest taken on Day 1 showing features of
pulmonary edema – perihilar opacities
Any ACS occurring in the setting of allergy is described
as Kounis Syndrome (KS).
Hence, CAG is not needed for diagnosis. It may be
needed for therapy.
Type1 – KS with no underlying CAD; can be treated with
adrenaline, antihistamines, steroids, vasodilators and
mast cell stabilizers. No anti-platelets indicated.
Type2 – KS in patients with underlying CAD; can be
treated with same drugs as Type 1 KS PLUS standard ACS
protocol (i.e. anti-platelets indicated).
Type3 – KS occurring as post procedure stent
thrombosis; can be treated same as Type-2 PLUS
aspiration of intrastent thrombus.