Recognizing Kounis Syndrome, the Unusual Possible Culprit of Acute Coronary Syndrome: A Rare Case Report

Abstract

Kounis syndrome encompasses acute coronary syndrome features associated with severe vasospasm of the coronary artery. It is related to allergic anaphylactic reaction triggered by the release of inflammatory cells and mediators. This entity, however, is often not properly diagnosed. In this report, we aimed to discuss a case of Kounis syndrome mimicking acute coronary syndrome. We presented a 58-year-old man with dyspnea, chest pain, dizziness, and itchiness 30 minutes following sodium diclofenac ingestion. His physical examination was remarkable for shock with hypoxia and features of anaphylactic reaction. An urgent electrocardiogram was obtained, manifesting deep ST-segment depression in anterolateral leads with ST elevation of aVR, which hinted a severe three-vessel disease or left main disease. Allergic acute coronary syndrome was suspected. Thus, the patient was managed with fluid resuscitation, epinephrine, and corticosteroid injection along with acute coronary syndrome treatment algorithm with a favorable clinical response. One-hour serial ECG showed complete resolution of ST depression with aVR normalization. This pointed to possible acute coronary spasm. No further coronary intervention was performed, the patient was discharged after 2 days in good condition and planned for further cardiac evaluation during follow-up. Kounis syndrome is an intriguing process caused by the presence of two disease entities that must be treated simultaneously. The difficulty in treating this condition stems from the fact that treating one of both entities may aggravate the other. Thus, a comprehensive approach and health education are strongly advised to ensure that this condition does not reoccur in the future.

Keywords: Kounis syndrome; acute coronary syndrome; anaphylaxis reaction; case report.

Fig. 1

Presented angioedema of the lower lip induced by sodium diclofenac in our patient.

Fig. 2

( A ) Initial electrocardiogram showing ST-segment depression in anterolateral leads and ST elevation of aVR. ( B ) One-hour serial electrocardiogram showing ST-segment depression resolution and normalization of aVR.

Fig. 3

Chest X-ray showing cardiomegaly with no signs of pulmonary edema.