Kounis Syndrome: Kill Two Birds With One Stone

J INVASIVE CARDIOL 2021;33(11):E920-E921.

Key words: allergy, cefazolin, Kounis syndrome, ST change, two variants

A 59-year-old man with a 95% stenosis in his diagonal branch (Figure 1) and no stenosis in the right coronary artery (RCA) or left circumflex artery was scheduled for percutaneous coronary intervention. A balloon angioplasty followed by a drug-coated balloon application achieved an acceptable result (Figure 2A, 2B). After prophylactic intravenous cefazolin administration for Proglide-site infection prevention, he started feeling general itching with palmar and cheek redness without any hemodynamic compromise, which resulted in methylprednisolone administration. However, ST elevation appeared in the inferior leads (Figure 3B), suggesting a potential RCA spasm. From these circumstances, a diagnosis of type I Kounis syndrome (KS) was made. Despite 2 puffs of nitroglycerin, the ST elevation persisted when bradycardia and hypotension progressed, and he became unconscious. While giving him intravenous epinephrine to maintain his hemodynamics, the ST level recovered, and he became fully conscious. When he complained of chest pain, a new ST elevation was noticed in the lateral leads, with ST levels in the inferior leads turning into depression (Figure 3C). Repeat angiography demonstrated neither spasm nor occlusion in the RCA (not shown), while the diagonal branch was completely occluded at the proximal portion (Figure 2C), which was considered to be responsible for ST elevation in the lateral leads. At that point, a diagnosis of type II KS was made. A drug-eluting stent implantation successfully restored blood flow (Figure 2D) and electrocardiographic changes returned to baseline (Figure 3D). Subsequently, his intradermal test was positive for cefazolin. This is the first reported case that combined 2 variants of KS in a single event.

From the ¹Department of Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan; ²Department of Cardiology, University of Patras School of Medicine, Patras, Greece.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 26, 2021.

The authors report patient consent for the images used herein.

Address for correspondence: Takehiro Yamashita, MD, PhD, FACC, Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, 2-1-16-1, Miyanosawa, Nishiku, Sapporo, Hokkaido 063-0052, Japan. Email: t_yamashita@cvc-ohno.or.jp