Successful Treatment of Kounis Syndrome Type I Presenting as Cardiac Arrest with ST Elevation

Correspondence To the Editor: Kounis syndrome describes a group of symptoms that manifest as unstable vasospastic or nonvasospastic angina or as acute myocardial infarction. It is triggered by the release of inflammatory mediators after an allergic reaction. A 74‑year‑old man with urinary incontinence was treated with a radical cystectomy using the Mainz pouch procedure and ureteroscopic lithotripsy. He underwent the third infusion of contrast agent (iopromide) for evaluation of pleural effusion in the right lower field of the lung. Two infusions of APCT with Iomeron ® (Iomeprol) contrast medium had previously been administered to this patient. The patient did not have a history of allergies or cardiac issues, although he had previously experienced nausea and vomiting as a contrast agent side effect. In this case, the patient did not complain of symptoms during infusion; however, he did lose consciousness after administration of the contrast agent. Initial heart rhythm could not be measured, as an electrocardiogram (ECG) monitoring system was not available at the time. Following transfer to the emergency department, the patient was evaluated and found to be in a deep coma (Glasgow Coma Scale 3 [E1V1M1]), with agonal gasping and pulseless carotid and femoral arteries. The ECG revealed ST elevation in leads II, III, and aVF and ST depression in the precordial lead [Figure 1]. The patient's blood pressure and respiratory rate were not measured and temporary cardiopulmonary arrest occurred. He received basic cardiopulmonary support and, as systolic blood pressure was unknown, an intravenous injection of 1 mg epinephrine, 4 mg chlorpheniramine, and 125 mg methylprednisolone was administered. When evaluated approximately 5 min after collapse, spontaneous circulation and respiration resumed. A cardiac echo examination was urgently performed and hyperkinetic wall motion was observed. After circulatory stabilization, the patient was transferred to the coronary angiography room. No stenosis or obstruction was observed and the patient was diagnosed with vasospasm caused by an allergic reaction to the contrast agent (Kounis syndrome Type I) and subsequently transferred to the Intensive Care Unit. He did not experience any chest pain, ST elevation was not observed on the cardiogram, and creatine phosphokinase and troponin T did not increase during his stay. The patient was discharged on the 5 th hospital day. Kounis syndrome is defined as the concurrence of acute coronary syndromes with conditions associated with mast cellactivation, involving interrelated and interacting inflammatory cells, and includes allergic or hypersensitive and anaphylactic or anaphylactoid reactions. …