Different types of Kounis syndrome caused by different episodes of bee sting anaphylaxis: Misfortunes never come singly

Abstract

We report our experience with a 69-year-old man who had different types of Kounis syndrome over a short time frame, caused by two episodes of bee sting anaphylaxis. After his first allergic reaction to a bee sting, he experienced a non-ST-segment elevation myocardial infarction; he was treated with percutaneous coronary intervention for near-occlusion of his right coronary artery. This episode was deemed type 2 Kounis syndrome. Four weeks later, we electively treated the nonculprit residual stenosis in his left anterior descending artery. Unfortunately, 2 weeks after this elective procedure, he experienced anaphylactic shock due to a second bee sting. Electrocardiography showed ST elevation in the anterior leads, and emergent coronary angiography showed thrombotic occlusion of the newly implanted stent in the left anterior descending artery. This second episode was deemed type 3 Kounis syndrome.

Learning objectives: This is a rare example of different types of Kounis syndrome resulting from repeated exposures to an allergic source, an example that deepens our understanding of Kounis syndrome. This patient's experience illustrates the need for careful evaluation of the indications for revascularization of nonculprit lesions in patients with a history of Kounis syndrome.

Keywords: Case report; Kounis syndrome; ST elevation myocardial infarction; Stent thrombosis.

Fig. 1

Electrocardiography (ECG), echocardiography, coronary angiography (CAG) during the first episode. (A) ECG on admission shows slight ST depression in the inferior leads (blue arrowheads). (B) Parasternal short-axis view of the left ventricle on echocardiography shows hypokinesis in the inferior wall (yellow arrowheads). (C) Initial CAG shows near-occlusion in the proximal right coronary artery (RCA) and moderate stenosis in the proximal left anterior descending artery. (D) Final CAG shows recanalization of the culprit lesion with a drug-eluting stent in place (white dotted curve); the moderate stenosis is assessed using a fractional flow reserve wire (green arrowheads).

Fig. 2

Elective percutaneous coronary intervention for the proximal left anterior descending lesion, 4 weeks after the first event. (A) Initial coronary angiography (CAG) for the left coronary artery. (B) After predilation, a drug-eluting stent is deployed in the proximal left anterior descending artery (LAD). (C) Final CAG shows that the LAD lesion has good coronary flow. Stents are shown with white dotted curves. (D) Final optical frequency domain imaging shows adequate stent expansion.

Fig. 3

Emergent percutaneous coronary intervention for left anterior descending stent thrombosis, 6 weeks after the first event. (A) Electrocardiography on admission for the second event shows ST elevation in the anterior leads (blue arrowheads). (B) Initial coronary angiography (CAG) shows occlusion of the left anterior descending artery (LAD) stent (pink arrowheads) and a patent right coronary artery (RCA) stent. (C) Intravascular ultrasonography (white arrow) shows thrombus occlusion of the LAD stent. (D) Final CAG shows recanalization of the LAD stent after plain old balloon angioplasty (POBA). Stents are shown with white dotted curves.