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A Young Patient With Hives and Chest Pain

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A patient in their 20s presented to the emergency department with presyncope, hives, and nausea after walking outside in the cold. On arrival, their pulse was 120 beats per minute; blood pressure, 85/52 mm Hg; respiratory rate, 20 breaths per minute; oxygen saturation, 100% with a nonrebreather mask; and temperature, 36.8° C. The patient was in moderate respiratory distress, and chest auscultation revealed bilateral wheezing. They were treated for presumed anaphylaxis with 0.5 mg of epinephrine intramuscularly. Immediately after the administration of epinephrine, they developed a headache, nausea, and chest pain. A 12-lead electrocardiogram (ECG) was obtained 5 minutes later (Figure 1). The patient had persistent hypotension.

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Kounis syndrome (acute coronary vasospasm associated with anaphylactoid response)

C. Give a second dose of 0.5 mg of intramuscular epinephrine

Kounis syndrome is a pathological state of acute coronary vasospasm with mast cell degranulation and interaction with other inflammatory cells secondary to allergic or hypersensitivity and anaphylactic or anaphylactoid insults.1,2 The inflammatory mediators involved include histamine, arachidonic acid, neutral protease, and platelet-activating factors.1,3 Coronary arteries can be the primary site during anaphylaxis and result in Kounis syndrome manifestations.1,3 Kounis syndrome can be precipitated by many factors, including angioedema, urticaria, hay fever, food allergy, Hymenoptera stings, latex, and drugs.1,2

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Article Information

Corresponding Author: Maxim Ben-Yakov, MDCM, Division of Emergency Medicine, University of Toronto, Toronto General Hospital, 480-200 Elizabeth St, R. Fraser Elliot Building, Ground, Toronto, ON M5G 2C4, Canada (maxim.benyakov@utoronto.ca).

Published Online: April 21, 2021. doi:10.1001/jamacardio.2021.0749

Conflict of Interest Disclosures: None reported.

References
1.
Kounis  NG , Mazarakis  A , Tsigkas  G , Giannopoulos  S , Goudevenos  J .  Kounis syndrome: a new twist on an old disease.   Future Cardiol. 2011;7(6):805-824. doi:10.2217/fca.11.63PubMedGoogle ScholarCrossref
2.
Kounis  NG .  Coronary hypersensitivity disorder: the Kounis syndrome.   Clin Ther. 2013;35(5):563-571. doi:10.1016/j.clinthera.2013.02.022PubMedGoogle ScholarCrossref
3.
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-2016-0010PubMedGoogle ScholarCrossref
4.
Sueda  S , Sasaki  Y , Habara  H , Kohno  H .  Editorial: Kounis syndrome (allergic angina and allergic myocardial infarction) for cardiologists.   J Cardiol Cases. 2015;12(4):110-112. doi:10.1016/j.jccase.2015.07.006PubMedGoogle ScholarCrossref
5.
Memon  S , Chhabra  L , Masrur  S , Parker  MW .  Allergic acute coronary syndrome (Kounis syndrome).   Proc (Bayl Univ Med Cent). 2015;28(3):358-362. doi:10.1080/08998280.2015.11929274PubMedGoogle ScholarCrossref
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