Kounis Syndrome

Kounis Syndrome

Kounis syndrome is an acute coronary syndrome associated with a hypersensitivity / anaphylactic phenomenon. Three types of Kounis syndrome have been described:

• Type I: Anaphylactic reaction causing coronary spasm in normal or near normal coronary arteries and may progress to myocardial infarction
• Type II: Anaphylactic  reaction combined with a pre-existing atheromatous coronary lesion can result in acute myocardial infarction
• Type III: Hypersensitivity to an intracoronary stent resulting in  severe stent thrombosis

Thus anaphylaxis can cause coronary spasm leading to acute myocardial infarction and life threatening cardiac arrhythmias like ventricular fibrillation and cause death. Anaphylaxis is often associated with type I or II Kounis syndrome causing coronary artery spasm and thrombosis. The nickel contained in coronary stents and the polymer coating of drug eluting stents have antigenic properties [1]. It can cause local hypersensitivity phenomena which can lead to stent thrombosis in the worst case [2].

Nicholas G Kounis, George D Soufras, Grigorios Tsigkas and George Hahalis in a letter to the editor [3] argue that Kounis hypersensitivity coronary syndrome caused by an antigenic complex of polymers, scaffolds and drugs – both the eluted and systemically administered could be involved in thrombosis of stents and scaffolds. They also suspect that the early and mid term scaffold thrombosis at around thirty days noted in the GHOST-EU registry [4] may also have hypersensitivity as contributor.

Kounis syndrome after Hornet sting has also been reported [5]. The stings can induce acute coronary syndrome both by direct toxic effect of the venom on the coronary endothelium or indirectly through the inflammatory mediators release during the allergic reaction. Widespread ST depression and T wave inversions occurring within half an hour, persisting for five hours and then reverting was documented. There was also associated hypotension.

Proteases released from the stimulated mast cells during hypersensitivity activate the matrix metalloproteinases which in turn cause breakdown of fibrous caps of atheroma. Breakdown of the fibrous cap of the plaques makes them vulnerable to rupture and local thrombosis leading to acute coronary syndrome.

Epirubicin-induced Kounis syndrome has been described by Liang HZ et al [6]. Epirubicin was being given by intra-iliac artery injection for recurrent bladder cancer. Systemic allergic reaction and chest pain with ECG changes and elevation of troponin was noted. Emergency coronary angiogram showed right coronary artery spasm without any stenosis of other vessels. Similar report of Type 1 Kounis syndrome after paclitaxel infusion for adenocarcinoma of lung has also been documented in literature [7].

References

1. Kounis NG, Soufras GD, Hahalis G. Anaphylactic cardiac collapse, sudden death and the Kounis syndrome. J Postgrad Med. 2014;60:227-9.
2. Kounis NG, Hahalis G, Theoharides TC. Coronary stents, hypersensitivity reactions, and the Kounis syndrome. J Interv Cardiol. 2007;20:314-323.
3. Nicholas G Kounis, George D Soufras, Grigorios Tsigkas, George Hahalis. Are bioabsorbable and biodegradable polymer scaffolds still safe or Kounis syndrome is still watching for? Chin Med J (Engl). 2014;127:4159.
4. Davide Capodanno, Tommaso Gori, Holger Nef, Azeem Latib, Julinda Mehilli, Maciej Lesiak, Giuseppe Caramanno, Christoph Naber, Carlo Di Mario, Antonio Colombo, Piera Capranzano, Jens Wiebe, Aleksander Araszkiewicz, Salvatore Geraci, Stelios Pyxaras, Alessio Mattesini, Toru Naganuma, Thomas Münzel, Corrado Tamburino. Percutaneous coronary intervention with everolimus-eluting bioresorbable vascular scaffolds in routine clinical practice: early and midterm outcomes from the European multicentre GHOST-EU registry. EuroIntervention. 2015 Feb;10(10):1144-53.
5. Dissanayake Mudiyanselage Priyantha Udaya Kumara Ralapanawa, Senanayake Abeysinghe Mudiyanselage Kularatne. A case of Kounis syndrome after a hornet sting and literature review. BMC Res Notes. 2014 Dec 3;7:867.
6. Liang HZ, Zhao H, Gao J, Cao CF, Wang WM. Epirubicin-induced Kounis syndrome. BMC Cardiovasc Disord. 2021 Mar 12;21(1):133. 
7. Wang B, Sethwala A, Gurvitch R. Type 1 Kounis syndrome after paclitaxel infusion in a patient treated for lung adenocarcinoma. Intern Med J. 2021 Mar;51(3):448-449.