A case of Kounis syndrome associated with transcatheter arterial chemoembolization for hepatocellular carcinoma

Abstract

Kounis syndrome, which is known as allergic angina and allergic myocardial infarction today, was described as the coexistence of acute coronary syndrome with allergic reactions in 1991 by Kounis and Zavras. We report a case of a 79-year-old man with hypertension, hepatocellular carcinoma (HCC), and no allergic history. He had received transcatheter arterial chemoembolization (TACE) for treatment of HCC five times without allergic reactions. At the sixth time of TACE, he presented an anaphylactic reaction such as systemic erythema and severe arterial hypotension. Simultaneously, he complained of anterior chest pain and electrocardiogram showed significant ST segment elevation in inferior leads, indicating inferior myocardial infarction. Emergency coronary angiography, however, did not demonstrate any organic stenoses or occluded lesions of the coronary arteries. We made the diagnosis of Kounis syndrome associated with TACE. Although Kounis syndrome is a rare condition, physicians should be aware of possible co-occurrence of anaphylactic reactions and acute coronary syndrome. <Learning objective: Kounis syndrome refers to acute coronary syndrome associated with allergic or anaphylactic reactions. Physicians have to be aware and keep Kounis syndrome in mind whenever they encounter patients with an anaphylactic reaction. And immediate diagnosis and prompt treatment are needed.>.

Keywords: Acute coronary syndrome; Anaphylactic reaction; Kounis syndrome; Transcatheter arterial chemoembolization.

Fig. 1

Electrocardiogram of the patient on heart attack. Electrocardiogram was taken when the patient complained of anterior chest pain. Electrocardiogram showed ST segment elevation in II, III, aVF leads and complete atrioventricular block with junctional escape rhythm (A). Electrocardiogram showed normalization of ST segment when the patient was referred to cardiac catheterization laboratory (B).

Fig. 2

Coronary angiography of the patient. Angiography of right coronary artery (RCA) at left anterior oblique (LAO) view revealed no stenosis or occlusion without intracoronary administration of nitroglycerin (A). Angiography of RCA after intracoronary administration of nitroglycerin revealed no stenosis and marked dilatation compared with control angiography at LAO (B) and at LAO cranial view (C).