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Cardiology

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

JAMA Cardiology

Published Online: April 21, 2021

JAMA Cardiology Clinical Challenge

Article Information and Disclosures

Maxim Ben-Yakov, MDCM¹;

Vigil James, MD²;

Brant Slomovic, MD^3,4

Author Affiliations

¹Division of Emergency Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
²Children’s Emergency Department, KK Women’s and Children’s Hospital PTE Ltd, Singapore
³Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
⁴University Health Network, University of Toronto, Toronto, Ontario, Canada

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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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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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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

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Kounis NG . Coronary hypersensitivity disorder: the Kounis syndrome. Clin Ther. 2013;35(5):563-571. doi:10.1016/j.clinthera.2013.02.022 PubMed Google Scholar Crossref

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 PubMed Google Scholar Crossref

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.2015.07.006 PubMed Google Scholar Crossref

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:10.1080/08998280.2015.11929274 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.