Epirubicin-induced Kounis syndrome

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Abstract

Background

Kounis syndrome is an acute coronary syndrome that appears in the setting of anaphylactic reaction or hypersensitivity. Many drugs and environmental exposures have been identified as potential offenders, and diagnosis and treatment can be challenging.

Case presentation

A 62-year-old man with recurrent bladder cancer underwent an intra-iliac artery epirubicin injection. After the injection, he developed chest pain and a systemic allergic reaction, with electrocardiographic alterations and elevated troponin-I levels. Emergent coronary angiography showed right coronary artery spasm and no stenosis of the other coronary arteries. This reaction was considered compatible with an allergic coronary vasospasm. A diagnosis of Kounis syndrome was made.

Conclusions

Kounis syndrome is common, but a prompt diagnosis is often not possible. This case is the first to suggest that an intraarterial epirubicin injection could potentially be one of its triggers. All physicians should be aware of the pathophysiology of this condition to better recognize it and start appropriate treatment; this will prevent aggravation of the vasospastic cardiac attacks and yield a better outcome.

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Most cited references 25

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Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology.

A Muraro, G. Roberts, M Worm … (2014)

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management.

Nicholas G. Kounis (2016)

Kounis syndrome has been established as a hypersensitivity coronary disorder induced by various conditions, drugs, environmental exposures, foods and coronary stents. Allergic, hypersensitivity, anaphylactic and anaphylactoid reactions are associated with this syndrome. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute are the three reported, so far, variants of this syndrome. Apart from coronary arteries, it affects the cerebral and mesenteric arteries. Its manifestations are broadening and its etiology is continuously increasing. Kounis syndrome is a ubiquitous disease which 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 seems to be not a rare disease but an infrequently diagnosed clinical entity which has revealed that the same mediators released from the same inflammatory cells are also present and in acute coronary events of non allergic 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, awareness of etiology, epidemiology, pathogenesis and clinical manifestations seems to be important for its prognosis, diagnosis, treatment, prevention.

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Cisplatin plus gemcitabine versus paclitaxel plus gemcitabine as first-line therapy for metastatic triple-negative breast cancer (CBCSG006): a randomised, open-label, multicentre, phase 3 trial.

Xi-chun Hu, Jian Carrot-Zhang, Bing-He Xu … (2015)

Platinum chemotherapy has a role in the treatment of metastatic triple-negative breast cancer but its full potential has probably not yet been reached. We assessed whether a cisplatin plus gemcitabine regimen was non-inferior to or superior to paclitaxel plus gemcitabine as first-line therapy for patients with metastatic triple-negative breast cancer.

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Author and article information

Contributors

Hui-zhu Liang: lianghuizhu@yeah.net.com

Hong Zhao: hong.zhao@medmail.com.cn

Jian Gao: gaojian785@163.com

Cheng-fu Cao: caochengfu85@163.com

Wei-min Wang:

ORCID: http://orcid.org/0000-0003-4953-0777

weiminwang@vip.sina.com

Journal

Journal ID (nlm-ta): BMC Cardiovasc Disord

Journal ID (iso-abbrev): BMC Cardiovasc Disord

Title: BMC Cardiovascular Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2261

Publication date (Electronic): 12 March 2021

Publication date PMC-release: 12 March 2021

Publication date Collection: 2021

Volume: 21

Electronic Location Identifier: 133

Affiliations

[1 ]GRID grid.411634.5, ISNI 0000 0004 0632 4559, Department of Cardiology, , Peking University People’s Hospital, ; Beijing, China

[2 ]GRID grid.411634.5, ISNI 0000 0004 0632 4559, Department of Radiology, , Peking University People’s Hospital, ; Beijing, China

Author information

Wei-min Wang http://orcid.org/0000-0003-4953-0777

Article

Publisher ID: 1936

DOI: 10.1186/s12872-021-01936-4

PMC ID: 7953621

SO-VID: f672fe3f-8fa0-47eb-82fb-47b7159309e9

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 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 in a credit line to the data.

History

Date received : 16 October 2020

Date accepted : 25 February 2021

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100010909, Young Scientists Fund;

Award ID: 81800316

Award Recipient : Cheng-fu Cao

Custom metadata

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: kounis syndrome,epirubicin,allergy,hypovolemic shock,acute coronary syndrome

Data availability:

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: kounis syndrome, epirubicin, allergy, hypovolemic shock, acute coronary syndrome

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Epirubicin-induced Kounis syndrome

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Abstract

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Case presentation

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Cardiovascular Innovations and Applications

Most cited references 25

Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology.

Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management.

Cisplatin plus gemcitabine versus paclitaxel plus gemcitabine as first-line therapy for metastatic triple-negative breast cancer (CBCSG006): a randomised, open-label, multicentre, phase 3 trial.

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