Kounis syndrome

Kounis syndrome (KS) is the simultane appearance of
acute coronary syndrome with circumstances accompanied
with mast cell degranulation and is precipitated via inflammatory
mediators released through the mast cell activation.
Generally, in published cases with KS, ST elevations on
electrocardiogram (ECG) and marked cardiac enzyme elevations
including troponins were observed. Here, we introduce a
case who represented with symptoms of allergic angina
without any finding on ECG and troponin elevation. Cardiac
magnetic resonance imaging, on the second day, showed
tapering of myocardium, hypokinesis in cardiac apex and
apicoposterior septum, and minimal pericardial effusion
adjacent to apex. We suggest that cardiac damage can happen
in patients without any ECG and cardiac enzyme abnormality
in KS. For chosen patients without any history of acute
coronary syndrome, ECG change, and troponin elevation, we
offer early use of cardiac magnetic resonance imaging, which
is noninvasive and needs hypoallergic gadolinium for contrast
imaging to show cardiac damage indirectly.

Background: Thus far, there are only case reports about allergic angina (Kounis Syndrome, KS). Neither incidence nor imaging
findings have been reported.
Aim: To determine the incidence of KS and evaluate the role of cardiac magnetic resonance imaging (CMRI) in detecting KS
among allergy patients in the emergency department (ED).
Material and Methods: The study population included patients over 18-year-old suffering from KS. Detection of pathologies on
at least one of the electrocardiogram (ECG), cardiac enzyme, or CMRI tests was identified as the criterion for KS. As part of the
CMRI procedure, T2-weighted imaging, early gadolinium enhancement, and late gadolinium enhancement were performed.
Results: Incidences of KS in all admissions and among allergy patients were 19.4 per 100 000 and 3.4%, respectively. The
most common etiology was the use of medications (81%). Of the patients, 47.6% described palpitations, 71.4% chest pressure, 52.4%
shortness of breath, and 14.3% syncope. Examinations showed that 76.2% of the patients had hives, 47.6% oedema of the uvula, 24%
angioneurotic oedema, and 19% hypotension. CMRI showed early-stage subendocardial contrast involvement and oedema in T2-
weighted images in all patients, pericardial effusion in 28.6%, and hypokinesis in the contrast defect site in 38.1%. The ECG results
for 4 patients (19.1%) were normal, and only 4 patients had a high troponin level.
Conclusion: These patients almost always present with reversible changes in the CMRI. The left ventricular lateral wall and
the septal region of the heart are particularly sensitive to KS according to the CMRI findings