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      A case of Kounis syndrome after a hornet sting and literature review

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          Abstract

          Background

          Acute coronary syndrome after hymenoptera stings or exposure to environment toxins is referred to as the Kounis syndrome or allergic myocardial ischaemia with or without infarction. We report a case of hornet (Vespa affinis) sting causing Kounis syndrome in Sri Lanka and present a review of literature.

          Case presentation

          A 60-year -old female with diabetes mellitus and known allergy to bee venom was stung by a hornet on the right hand. Within 30 minutes she developed hypotension and wide spread T wave inversion in the 12 leads ECG that remained unchanged about 5 hours and reversed back to normal.

          Conclusion

          Hymenoptera stings can induce acute coronary syndrome either by direct effect of venom constituents on the coronary endothelium or through inflammatory mediators induced allergic reaction on coronary vasculature. Early recognition of Kounis syndrome is needed in hornet stings to implement necessary treatments.

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          Most cited references17

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          Bee and Wasp Venoms

          E Habermann (1972)
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            Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm?

            Nicholas G. Kounis (2006)
            Inflammatory mediators including histamine, neutral proteases, arachidonic acid products, platelet activating factor and a variety of cytokines and chemokines are increased in blood or urine in both allergic episodes and acute coronary syndromes. The release of mediators during allergic insults has been incriminated to induce coronary artery spasm and/or atheromatous plaque erosion or rupture. A common pathway between allergic and non-allergic coronary syndromes seems to exist. Today, there is evidence that mast cells not only enter the culprit region before plaque erosion or rupture but they release their contents before an actual coronary episode. Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation including allergic or hypersensitivity and anaphylactic or anaphylactoid insults. It is caused by inflammatory mediators released through mast cell activation. Kounis syndrome, as consequence, of the above pathophysiologic association is regarded as nature's own experiment and magnificent natural paradigm showing novel way in an effort to prevent acute coronary syndromes. Drugs and natural molecules which stabilize mast cell membrane and monoclonal antibodies that protect mast cell surface could emerge as novel therapeutic modalities capable to prevent acute coronary and cerebrovascular events.
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              Clonal mast cell disorders in patients with systemic reactions to Hymenoptera stings and increased serum tryptase levels.

              Patrizia Bonadonna, Omar Perbellini, Giovanni Passalacqua … (2009)
              Anaphylaxis after Hymenoptera stings has been reported in subjects with mastocytosis, but few data exist regarding disease prevalence in populations allergic to these insects. The incidence of clonal mast cell (MC) disorders in subjects with both systemic reactions to Hymenoptera stings and increased serum baseline tryptase (sBT) levels was assessed by using bone marrow (BM) aspirates and biopsy specimens. Subjects with a history of a systemic reaction caused by a Hymenoptera sting underwent the standard diagnostic work-up for Hymenoptera allergy, and sBT levels were measured. Subjects with an increased sBT level had BM evaluation that included histology/cytology, flow cytometry, and detection of KIT mutations. Forty-four (11.6%) of 379 subjects with systemic reactions had increased sBT levels (>11.4 ng/mL), and 31 (70.5%) of these had a history of anaphylaxis. Thirty-four subjects with increased sBT levels underwent a BM analysis. Histology detected diagnostic or subdiagnostic MC infiltrates in 22 (65%) of 34 patients. Abnormal MCs were identified by means of flow cytometry and cytology in 26 (78.8%) of 33 and 20 (58.8%) of 34 subjects, respectively. A KIT mutation was detected in 17 (54.8%) of 31 subjects. The diagnosis was indolent systemic mastocytosis in 21 (61.7%) of 34 subjects and monoclonal MC activation syndrome in 9 (26.5%) of 34 subjects. All subjects with anaphylaxis had one of those 2 disorders. The concomitant presence of systemic reactions (especially anaphylaxis) after Hymenoptera stings and increased sBT levels strongly suggests that a BM examination is indicated for the diagnosis of clonal MC disease.
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                Author and article information

                Contributors
                Dissanayake Mudiyanselage Priyantha Udaya Kumara Ralapanawa: udayapralapanawa@yahoo.com
                Senanayake Abeysinghe Mudiyanselage Kularatne: samkul@sltnet.lk
                Journal
                Journal ID (nlm-ta): BMC Res Notes
                Journal ID (iso-abbrev): BMC Res Notes
                Title: BMC Research Notes
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1756-0500
                Publication date (Electronic): 3 December 2014
                Publication date PMC-release: 3 December 2014
                Publication date Collection: 2014
                Volume: 7
                Issue: 1
                Electronic Location Identifier: 867
                Affiliations
                Department of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
                Article
                Publisher ID: 3380
                DOI: 10.1186/1756-0500-7-867
                PMC ID: 4265414
                PubMed ID: 25465208
                SO-VID: 43a00971-17ee-4e61-9f9e-0cf007001e8a
                Copyright © © Ralapanawa and Kularatne; licensee BioMed Central Ltd. 2014
                License:

                This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 12 August 2014
                Date accepted : 26 November 2014
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2014

                ScienceOpen disciplines: Medicine
                Keywords: kounis syndrome,acute coronary syndrome,vespa affinis,sri lanka
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: kounis syndrome, acute coronary syndrome, vespa affinis, sri lanka

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