Kounis Syndrome Manifesting With Myocardial Infarction Due to Bi-Coronary Late Stent Thrombosis Following Anaphylaxis
© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
J INVASIVE CARDIOL 2025. doi:10.25270/jic/24.00366. Epub January 13, 2025.
A 70-year-old woman developed an anaphylactic reaction with syncope and inspiratory stridor after a wasp sting. Emergency treatment included epinephrine, cortisone, and antihistamines. The electrocardiogram (ECG) showed significant ST-segment elevation in the inferior and anterolateral leads. The patient had a history of coronary artery disease (CAD) with stents implanted in the right coronary artery (RCA) and left anterior descending artery (LAD) 2 and 5 years ago, respectively.
The emergency coronary angiography showed an intraluminal filling defect within the LAD stent, with Thrombolysis in Myocardial Infarction (TIMI)-2 flow (Figure A [1], Video 1), as well as diffuse intraluminal haziness in the RCA with severe in-stent stenosis in the distal segment, while TIMI-3 flow was preserved (Video 2). After wiring the LAD and diagonal branch, the initial filling defect resolved and TIMI-3 flow was re-established, implying a possible peripheral embolization of thrombus fragments following wire manipulation (Figure A [2], Video 3).
Despite restored LAD flow, the patient continued to experience chest pain and ECG abnormalities. The distal RCA stenosis was initially treated with drug-coated-balloons, following pre-dilatation with a non-compliant balloon. Optical coherence tomography (OCT) showed multiple intraluminal thrombi in both the stented and native segments of the RCA, which were interspersed with a stented segment without any significant lesion (Figure B, Videos 4 and 5).
Type 3 Kounis Syndrome is the occurrence of acute coronary syndromes caused by coronary stent thrombosis in the context of an allergic, hypersensitivity, anaphylactic, or anaphylactoid reaction.1,2 In our case, simultaneous stent thrombosis in 2 coronary arteries created an unusual and challenging angiographic scenario during primary percutaneous coronary intervention.
Affiliations and Disclosures
Francesco Ciotola, MD; Harald Rittger, MD; Stylianos A. Pyxaras, MD, PhD
From Klinikum Fürth, Department of Cardiology and Pneumology, Academic Teaching Hospital of the Friedrich-Alexander-University Erlangen-Nuremberg, Fürth, Germany.
Disclosures: Prof Rittger reports consulting fees for Siemens and Speaker´s fees for Novartis, Pfizer, Astra, and Boehringer. Dr Pyxaras reports proctorship and consultancy fees from Asahi Intecc, Biotronik, and Boston Scientific. The remaining author reports no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and for the anonymized publication of their data
Address for correspondence: Francesco Ciotola, MD, Department of Cardiology, University Hospital of the Friedrich-Alexander-University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen 91054, Germany. Email: francesco.ciotola@uk-erlangen.de
REFERENCES
- Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med. 2016;54(10):1545-1559. doi:10.1515/cclm-2016-0010
- Chen JP, Hou D, Pendyala L, Goudevenos JA, Kounis NG. Drug-eluting stent thrombosis: the Kounis hypersensitivity-associated acute coronary syndrome revisited. JACC Cardiovasc Interv. 2009;2(7):583-593. doi:10.1016/j.jcin.2009.04.017
