The more allergens an atopic patient is exposed to, the easier and quicker anaphylactic shock and Kounis syndrome appear: Clinical and therapeutic paradoxes

Abstract

Kounis syndrome is a condition that combines allergic, hypersensitivity, anaphylactic or anaphylactoid reactions with acute coronary syndromes including vasospastic angina, acute myocardial infarction and stent thrombosis. This syndrome is a ubiquitous disease affecting patients of any age, involving numerous and continuously increasing causes, with broadening clinical manifestations and covering a wide spectrum of mast cell activation disorders. Drugs, environmental exposures and various conditions are the main offenders. Clinical and therapeutic paradoxes concerning Kounis syndrome therapy, pathophysiology, clinical course and causality have been encountered during its clinical course. Drugs that counteract allergy, such as H2-antihistamines, can induce allergy and Kounis syndrome. The more drugs an atopic patient is exposed to, the easier and quicker anaphylaxis and Kounis syndrome can occur. Every anesthetized patient is under the risk of multiple drugs and substances that can induce anaphylactic reaction and Kounis syndrome. The heart and the coronary arteries seem to be the primary target in severe anaphylaxis manifesting as Kounis syndrome. Commercially available adrenaline saves lives in anaphylaxis but it contains as preservative sodium metabisulfite and should be avoided in the sulfite allergic patients. Thus, careful patient past history and consideration for drug side effects and allergy should be taken into account before use. The decision to prescribe a drug where there is a history of previous adverse reactions requires careful assessment of the risks and potential benefits.

Diagnostic Dilemma in Allergy and Coronary Syndromes: Kounis Syndrome or Adrenaline Effect?

“…Sulfite-related hypersensitivity and anaphylaxis in KS has been demonstrated in the literature. 4,5 The adrenaline-induced adrenergic side effect is another catecholamine-mediated problem. Adrenaline is the cornerstone in the management of anaphylaxis.…”

“…In these cases, the 3 No diagnostic test pathognomonic for KS exists and therapy should be directed against both allergic and cardiac symptoms. 3,4 The treatment strategy is another challenge in such patients since the drugs used to treat this syndrome may also aggravate the allergic symptoms or worsen ACS. Administration of adrenaline is controversial since the myocardium and coronary vessels are already prone to hypoperfusion due to anaphylaxis-mediated systemic vasodilatation and depressed cardiac output.…”

“…Administration of adrenaline is controversial since the myocardium and coronary vessels are already prone to hypoperfusion due to anaphylaxis-mediated systemic vasodilatation and depressed cardiac output. 3,4 Therefore, adrenaline should be used cautiously due to the theoretical risk of worsening coronary vasospasm and myocardial ischemia through the alpha receptor effect. Another point of note is a rare side effect of adrenaline; the drug itself triggers allergy due to sodium metabisulfite, which is an antioxidant and is used as a preservative.…”

Anaphylaxis during cardiac surgery for hypertrophic cardiomyopathy: patholophysiologic and therapeutic considerations

“…The latter also behaves as an allergen [12]. The question that arises in this report is whether or not the above-described patient was sulphite-sensitized.…”

“…All these anaesthetic drugs have been incriminated as inducing mild or severe allergic reactions [6][7][8][9][10][11]. Thus, physicians and anaesthetists should always remember that the more allergens a patient is exposed to, the easier and quicker anaphylactic shock and Kounis syndrome appear [12]. Furthermore, bronchodilator treatment with salbutamol (albuterol) can induce cardiovascular collapse as occurred in a 77-year-old-woman with an asthma exacerbation [13].…”