Death following ceftazidime-induced Kounis syndrome: Diagnostic considerations in the realm of forensic pathology

Kounis, Nicholas G.; Koniari, Ioanna; Tsigkas, Grigorios; Chourdakis, Emmanouil; Velissaris, Dimitrios; Soufras, George D.

doi:10.1177/0025817220902057

Cited by 5 publications

(11 citation statements)

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“…The microscopic analysis of coronary arteries can reveal the presence of inflammatory infiltrates (i.e., mast cells and eosinophils) in wall vessels, especially in the region of vasospasm occurrence. If coronary arteries are affected by atherosclerotic processes, the inflammatory infiltrates are usually described in the plaques themselves [ 22 , 23 ]. At routine histology, the myocardial tissue might reveal clear signs of myocardial infarction, usually described as foci of coagulative necrosis with neutrophil infiltration [ 24 ].…”

Section: Discussionmentioning

confidence: 99%

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Fatal Outcome Due to Kounis Syndrome Following Fluorescein Retinal Angiography: A Case Report

Cianci,

Pitrone,

Sapienza

et al. 2024

Diagnostics

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Kounis Syndrome (KS) is a clinical entity triggered by allergic or hypersensitivity reactions capable of inducing acute coronary events. Several causes can induce KS, including drugs and insect stings. Here, a rare case of post mortem assessment of fatal KS related to fluorescein retinal angiography has been reported. An 80-year-old man in follow-up for a retinal vein thrombosis underwent a retinal fluoroangiography. Approximately 30 min later, the patient complained of sweating and dizziness, and suddenly lost consciousness due to a cardiac arrest. Despite the immediate cardiopulmonary resuscitation, he died. The autopsy revealed foamy yellowish edema in the respiratory tract and coronary atherosclerosis with eccentric plaques partially obstructing the lumen. The routine histology highlighted lung emphysema and myocyte break-up with foci of contraction band necrosis at the myocardial tissue. Biochemistry showed increased serum tryptase, troponin, and p-BNP. Activated and degranulated (tryptase) mast cells were detected, using immunohistochemistry, in the larynx, lungs, spleen, and heart. Acute myocardial ischemia due to allergic coronary vasospasm related to fluorescein hypersensitivity has been assessed as cause of death. KS-related deaths are considered rare events, and the post mortem assessment of KS quite difficult. The integration of several investigations (gross and microscopic examination, biochemistry, immunohistochemistry) can provide useful findings to support the diagnosis, helping to reduce the unrecognized cases as much as possible.

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Section: Discussionmentioning

confidence: 99%

“…Several tryptase-level cut-offs have been reported in forensic literature. Kounis et al [ 22 ] described a value greater than 10 μg/L as a sensible and specific cut-off, while other researchers proposed a larger cut-off of 45 μg/L for serum tryptase measured on femoral blood [ 22 , 35 ].…”

Section: Discussionmentioning

confidence: 99%

Fatal Outcome Due to Kounis Syndrome Following Fluorescein Retinal Angiography: A Case Report

Cianci,

Pitrone,

Sapienza

et al. 2024

Diagnostics

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“…The diagnosis should be based on the integration of circumstantial and anamnestic data, autopsies, histological findings, and biochemical and immunohistochemical data [26,27]. This approach has a pivotal role also in those cases where the occurrence of KS is suspected after analyzing the anaphylaxis effectors in the biological fluids and in common target tissues, together with heart and coronary arteries [28].…”

Section: Postmortem Assessment Of Kounis Syndromementioning

confidence: 99%

“…In KS manifesting as coronary spasm, a high presence of mast cells has been found in the coronary arteries wall, including the area of the spasm, especially in the tunica adventitia [29][30][31][32][33]. Furthermore, many studies report that the major count of mast cells is concentrated in atherosclerotic and hemorrhagic plaques [28,29]. Histologically, myocardial alterations caused by the ischemic insult related to the compromission of coronaries due to heart anaphylactic involvement can be observed.…”

Section: Postmortem Assessment Of Kounis Syndromementioning

confidence: 99%

An Insight into Kounis Syndrome: Bridging Clinical Knowledge with Forensic Perspectives

Forzese,

Pitrone,

Cianci

et al. 2024

Life

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Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or hypersensitivity reactions. Incidence rates vary, with studies reporting 19.4 per 100.000 among all admissions and 3.4% among allergy patients. This review explores the expanding understanding of KS, encompassing various manifestations, and focusing on both clinical data and forensic findings useful in performing a diagnosis. The pathophysiology of this syndrome involves a complex interplay between allergic reactions and the cardiovascular system. Mast cell activation, histamine release, leukotrienes, cytokines, and platelet activation can contribute to coronary events. Three types of classification systems (allergic angina, allergic myocardial infarction, allergic stent thrombosis) aid in categorizing presentations. The diagnosis of KS relies on clinical presentation, laboratory findings, and imaging. Postmortem assessment of KS is based on the integration of circumstantial data, autopsy, and histological findings. Biochemical and immunohistochemical analyses also contribute to postmortem diagnosis. In conclusion, a combined, multidisciplinary approach should be used to ease the diagnostic process, which is crucial for forensic practitioners in confirming KS occurrence.

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“…Many drug classes have been linked to this syndrome, including antibiotics, antivirals, antifungal, nonsteroidal anti-inflammatory drugs, proton pump inhibitors, antihypertensive drugs, and antihistamines, among others. However, the most frequently culprit drugs are penicillins [ 8 ] and cephalosporins [ 9 , 10 ]. Insect bites are the next most frequent cause of Kounis syndrome followed by antibiotics, bees, and wasps.…”

Section: Introductionmentioning

confidence: 99%

Type III Kounis Syndrome Secondary to Ciprofloxacin-Induced Hypersensitivity

et al. 2022

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Kounis syndrome (KS) is a rare syndrome characterized by the co-occurrence of acute coronary syndromes in the setting of mast cell and platelet activation in response to hypersensitivity reactions. It can be manifested as coronary vasospasms, acute myocardial infarction, or stent thrombosis triggered by drugs, vaccines, foods, coronary stents, and insect bites. It is a life-threatening condition that needs to be adequately recognized for early diagnosis and appropriate treatment. In this case report, we present a 71-year-old patient with a history of arterial hypertension and non-ST elevation myocardial infarction six months earlier that was treated percutaneously with angioplasty plus stent implantation in the circumflex artery, who subsequently presented to the emergency department due to generalized itching associated with tongue swelling, dyspnea, and chest pain after ingestion of ciprofloxacin for the treatment of a urogenital infection. An electrocardiogram showed ST elevation in II, III, and aVF leads, and positive troponin; thus, a coronary arteriography was performed that showed complete thrombotic stent occlusion in the circumflex artery. Consequently, diagnosis of type 4b inferolateral acute myocardial infarction secondary to ciprofloxacin-triggered type III Kounis syndrome was made. The aim of this report is to understand the relationship between the allergic reaction to ciprofloxacin and the acute coronary syndrome, and to create awareness of the importance of early diagnosis and treatment of this potentially fatal syndrome.

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Death following ceftazidime-induced Kounis syndrome: Diagnostic considerations in the realm of forensic pathology

Cited by 5 publications

References 0 publications

Fatal Outcome Due to Kounis Syndrome Following Fluorescein Retinal Angiography: A Case Report

Fatal Outcome Due to Kounis Syndrome Following Fluorescein Retinal Angiography: A Case Report

An Insight into Kounis Syndrome: Bridging Clinical Knowledge with Forensic Perspectives

Type III Kounis Syndrome Secondary to Ciprofloxacin-Induced Hypersensitivity

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