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A Unique Challenge in Management in the Emergency Department and Cardiac Cathlab: Case Review of Two Subjects with Kounis Syndrome Complicated with ST Elevation Myocardial Infarction and Ventricular Tachycardia, Following Exposure to Cutaneous or Intravenous Allergens

Authors:

P. M. Athauda Arachchi ,

Durdans Hospital, Alfred Place, Colombo 3, LK
About P. M.
Kotelawala Defense University, Colombo
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N. Yahampath,

Durdans Hospital, Alfred Place, Colombo 3, LK
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S. Rajapakse

Durdans Hospital, Alfred Place, Colombo 3, LK
About S.
University of Colombo
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Abstract

Acute coronary syndromes, such as coronary spasm or acute myocardial infarction, have been reported following allergic reactions.  These are known to affect patients of any age, and can have a variety of clinical manifestations, and are collectively referred to as Kounis syndrome [1].  We report 2 cases of acute myocardial infarction complicated by severe cardiac dysrhythmia, following an acute allergic reaction to cutaneous or intravenous allergens. To our knowledge, this is the first instance of a skin contact with caterpillar has been documented to provoke Kounis syndrome complicated by an acute STEMI with polymorphic VT.  Management of such patients could be hazardous, particularly in emergency units and cardiac catheter labs, when decisions on drugs and urgent revascularization need to be made on a background of inflammation induced by severe allergic reactions. In theory, bare metal stents (when appropriate), Polymer free, Bio-absorbable scaffolds or rapid healing Drug Eluting Stents offer a better safety profile in emergency PCI, but according to our knowledge, duration of antiplatelet drugs and relative safety of various types of stents with variable drug and polymer combinations have not been formally evaluated in this condition in randomised control trials. The risk of early and late stent thrombosis and restenosis with chronic inflammation may be difficult to predict in the long term, without follow up data from trials. Such trials are very difficult to set up given the low volumes and emergency nature of events, hence review of clinical case series like ours will be invaluable to gain more insight into rapid decision making required in this interesting clinical syndrome. Reassuringly, both our patients who had emergency PCI with either Biolimus, Everolimus eluting or bare metal stents respectively in the acute setting, have not experienced repeat hospitalizations for ACS, arrhythmia or a repeat revascularization procedure at 7 and 5year follow-ups respectively.

How to Cite: Athauda Arachchi, P.M., Yahampath, N. and Rajapakse, S., 2022. A Unique Challenge in Management in the Emergency Department and Cardiac Cathlab: Case Review of Two Subjects with Kounis Syndrome Complicated with ST Elevation Myocardial Infarction and Ventricular Tachycardia, Following Exposure to Cutaneous or Intravenous Allergens. Sri Lanka Journal of Medicine, 31(1), pp.93–98. DOI: http://doi.org/10.4038/sljm.v31i1.316
Published on 15 Aug 2022.
Peer Reviewed

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