Kounis syndrome secondary to amoxicillin/clavulanic acid administration: a case report and review of literature

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Abstract

Background

Kounis syndrome is the concurrence of acute coronary syndromes with mast cells activation induced by hypersensitivity and anaphylactoid insults and is increasingly encountered in clinical practice. The main pathophysiological mechanism is vasospasm of the epicardial coronary arteries due to increased inflammatory mediators that are released during a hypersensitivity reaction.

Case presentation

A 74-year -old Sinhalese man with diabetes mellitus was admitted with four day history of high fever with chills and rigors. His urine analysis and blood investigations revealed evidence of urinary tract infection. After excluding allergic conditions, he was given amoxicillin/clavulanic acid intravenously. About 20 minutes after the first dose he felt severe itching of body, nausea , dizziness and sever retrosternal chest pain. Urgent electrocardiogram was taken and it showed widespread ST segment elevations. He was treated for anaphylactic shock as well as acute coronary syndrome and was able to be discharged within a few days.

Conclusion

This case highlights the occurrence of acute coronary syndrome following drug induced anaphylaxis. Acute coronary syndrome of this nature may be completely atypical and overlooked. Kounis syndrome should be borne in mind in the event of anaphylactic episode wherein the electrocardiogram becomes essential.

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Most cited references 16

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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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Kounis syndrome: a new twist on an old disease.

Nicholas G. Kounis, S Giannopoulos, Andreas Mazarakis … (2011)

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation, such as allergies or hypersensitivity and anaphylactic or anaphylactoid insults that can involve other interrelated and interacting inflammatory cells behaving as a 'ball of thread'. It is caused by inflammatory mediators such as neutral proteases including tryptase and chymase, arachidonic acid products, histamine, platelet activating factor and a variety of cytokines and chemokines released during the activation process. Platelets with FCεRI and FCεRII receptors also participate in the above cascade. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three reported variants of this syndrome. Kounis syndrome is a ubiquitus disease that represents a magnificent natural paradigm and nature's own experiment, in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture. Kounis syndrome can complicate anesthesia, vaccination, medical therapy and stent implantation and it seems to be associated with coronary allograft vasculopathy and takotsubo syndrome, it can often be confused with hypersensitivity myocarditis and can be the cause of unexplained sudden death. Kounis syndrome has revealed that the same mediators released from the same inflammatory cells are present in acute coronary events of nonallergic etiology. These cells are not only present in the culprit region before plaque erosion or rupture but they release their contents just before an actual coronary event. Therefore, does Kounis syndrome represent a magnificent natural paradigm and nature's own experiment in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture showing a novel way towards our effort to prevent acute coronary syndromes? Drugs, substances targeting the stem cell factor that is essential for mast cell development, proliferation, survival, adhesion and homing as well as monoclonal antibodies and natural molecules that protect mast cell surface and stabilize mast cell membrane could emerge as novel therapeutic ways capable to prevent acute coronary and acute cerebrovascular events.

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Allergic angina and allergic myocardial infarction: a new twist on an old syndrome.

Lazaros A Nikolaidis, Nicholas G. Kounis, Alan Gradman (2002)

A series of eight patients admitted to a single-centre coronary care unit over a two-year period is described. All of the patients presented with an acute coronary syndrome within less than 48 h from the onset of an allergic reaction (six patients), or during an acute asthmatic paroxysm (two patients). None of the patients had any history of cardiac diseases, yet two had risk factors and two were former smokers. Four patients developed subendocardial myocardial infarction, three developed transmural myocardial infarction and one had unstable angina with no elevation in cardiac enzyme levels. Coronary angiograms were performed in seven of the eight patients; hemodynamically significant stenosis (greater than 70%) of one or more coronary arteries was detected in all patients. All seven patients underwent successful revascularization and recovered without complications. The present observational report hypothesizes that atopic people expressing an amplified mast cell degranulation may be more vulnerable to plaque rupture.

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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): 26 March 2015

Publication date PMC-release: 26 March 2015

Publication date Collection: 2015

Volume: 8

Electronic Location Identifier: 97

Affiliations

[ ]Department of Medicine, Consultant Physician & Senior Lecturer, University of Peradeniya, Peradeniya, Sri Lanka

[ ]Department of Medicine, Senior Professor in Medicine, Senior Consultant Physician, University of Peradeniya, Peradeniya, Sri Lanka

Article

Publisher ID: 1072

DOI: 10.1186/s13104-015-1072-5

PMC ID: 4399411

SO-VID: 6c1ce181-7fe8-4584-9897-3b87e97f30c2

License:

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 : 15 December 2014

Date accepted : 19 March 2015

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ScienceOpen disciplines: Medicine

Keywords: kounis syndrome,amoxicillin/clavulanic acid,acute coronary syndrome

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ScienceOpen disciplines: Medicine

Keywords: kounis syndrome, amoxicillin/clavulanic acid, acute coronary syndrome

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Most cited references 16

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

Kounis syndrome: a new twist on an old disease.

Allergic angina and allergic myocardial infarction: a new twist on an old syndrome.

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