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Allergy Induced Myocardial Infarction - Kounis Syndrome / Coronary Hypersensitivity Disorder / Vasospastic Angina

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Manievelraaman Kannan
Manievelraaman Kannan

Case Presentation PPT - For TAPICON 2021 Case Report: Allergy Induced Myocardial Infarction - Kounis Syndrome / Coronary Hypersensitivity Disorder / Vasospastic Angina. Abstract A young female with no coronary risk factors presented to us with history of chest pain, generalized urticarial rashes and itch suddenly following Inj.IM Diclofenac, which was given for heel pain relief. She was hemodynamically stable, but tachypneic, orthopneic with bilateral basal crepitations. ECG showed significant ST depression & T inversion in II,III,aVF and V2-V6 and ST elevation in aVR. CXR showed pulmonary edema. Echo revealed global hypokinesia of LV. Cardiac enzymes were elevated. Treated for acute coronary syndrome (ACS) and her pain got relieved. CAG showed normal epicardial coronaries. Repeat ECG showed regression of ST changes correlating with chest pain relief and enzymes were also falling. Pre-discharge, ECG normalised but echo showed persistence of global hypokinesia. Two weeks later, repeat echo showed dramatic improvement with normal LV systolic function suggesting recovery from myocardial stunning. This qualifies for the diagnosis of MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries). In the setting of allergic trigger, vasospasm or coronary hypersensitivity is the underlying mechanism - described as KOUNIS SYNDROME. ECG changes and chest discomforts that occur in allergic reactions are NOT ALWAYS SECONDARY to distributive/anaphylactic shock. Sometimes heart could be the primarily affected organ by the allergic reaction. It is frequently overlooked and its timely recognition and appropriate intervention will improve the outcome.

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Dr. MANIEVELRAAMAN.K 3rd year PG Institute of Internal Medicine MMC & RGGGH Chennai - 03 Case Report: ‘Allergy induced’ Myocardial Infarction - KOUNIS SYNDROME TAPICON 2021 - ePaper Presentation
Chief Complaints • Generalised Rash & Itch all over the body • Chest pain • Breathing difficulty • 3 hours duration • All started suddenly after IM injection of Diclofenac 21yr / Female - No co-morbidities / No coronary risk factors / No prior medical history
History of Present Illness Apparently normal the previous day except for her heel pain • Consulted her GP for the same and was given IM Diclofenac injection for pain relief • After few minutes, patient developed generalised urticarial rashes and itch all over the body followed by the development of chest tightness and then chest pain. • Identified as anaphylaxis and was given fluid resuscitation (1L bolus) and IM adrenaline along with Inj. Avil and Inj. Dexa. Her BP was normal. Observed for 1 hour. Her symptoms persisted and hence referred to RGGGH.
• C/O Breathlessness + • Worsened by lying down (Orthopnea +) • Lying flat elicits cough • No H/O PND • No H/O Palpitations • No H/O Pedal edema • No H/O Vomiting • No H/O LOC • No H/O Focal deficits • No H/O Seizures • No H/O Fever • No previous H/O suggestive of Connective tissue disease • No H/O Oliguria
On Examination • Conscious, Oriented, Afebrile, Tachypneic, Orthopneic • Vitals: HR: 88/min, BP: 100/70 mm Hg, RR: 28/min, SpO2: 94 % in RA • JVP elevated • No (Pallor, Icterus, Cyanosis, Clubbing, LN, Pedal Edema) • CVS: S1S2+, No added sounds, No murmur • RS: NVBS+, B/L Basal fine crepitations + • P/A: Soft, Non-tender, No organomegaly • CNS: NFND, B/L Pupils RTL
Investigations ECG on arrival • ST depression & T inversion in Lead II, III, aVF, V2 - V6 • ST elevation in aVR • HR: 88/min • Left Main pattern
Investigations • Echo: • Global hypokinesia of LV • IVC diameter: 2 cm • Cardiac enzymes elevated • CT chest: Pulmonary edema • CBC, RFT, LFT, Electrolytes: Normal
Investigations After 2 hours, when patient had a prompt pain relief but dyspnea persisted • Regression of previous ST-T changes correlating with chest pain relief
Investigations Prior to discharge • CAG: Normal Epicardial Coronaries • Echo: Hypokinesia of LV + • ECG: Normalisation of previous ST-T changes. No significant ST-T changes now Reviewing 2 weeks after discharge • Echo: Normal LV systolic function • ECG: Normal • Symptom free
Diagnosis • Anaphylaxis - NSAID (Diclofenac) induced • MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries) • Allergic trigger (?Vasospasm) - KOUNIS SYNDROME • Pulmonary edema (cardiogenic) - recovered
Not a rare disease occurrence But a rarely identified one • ECG CHANGES & CHEST DISCOMFORTS THAT OCCUR IN ALLERGIC REACTIONS • Not always secondary to anaphylactic / distributive shock • Heart could be the primarily affected organ causing downstream effects • Timely identification improves outcomes
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Allergy Induced Myocardial Infarction - Kounis Syndrome / Coronary Hypersensitivity Disorder / Vasospastic Angina

  • 1. Dr. MANIEVELRAAMAN.K 3rd year PG Institute of Internal Medicine MMC & RGGGH Chennai - 03 Case Report: ‘Allergy induced’ Myocardial Infarction - KOUNIS SYNDROME TAPICON 2021 - ePaper Presentation
  • 2. Chief Complaints • Generalised Rash & Itch all over the body • Chest pain • Breathing difficulty • 3 hours duration • All started suddenly after IM injection of Diclofenac 21yr / Female - No co-morbidities / No coronary risk factors / No prior medical history
  • 3. History of Present Illness Apparently normal the previous day except for her heel pain • Consulted her GP for the same and was given IM Diclofenac injection for pain relief • After few minutes, patient developed generalised urticarial rashes and itch all over the body followed by the development of chest tightness and then chest pain. • Identified as anaphylaxis and was given fluid resuscitation (1L bolus) and IM adrenaline along with Inj. Avil and Inj. Dexa. Her BP was normal. Observed for 1 hour. Her symptoms persisted and hence referred to RGGGH.
  • 4. • C/O Breathlessness + • Worsened by lying down (Orthopnea +) • Lying flat elicits cough • No H/O PND • No H/O Palpitations • No H/O Pedal edema • No H/O Vomiting • No H/O LOC • No H/O Focal deficits • No H/O Seizures • No H/O Fever • No previous H/O suggestive of Connective tissue disease • No H/O Oliguria
  • 5. On Examination • Conscious, Oriented, Afebrile, Tachypneic, Orthopneic • Vitals: HR: 88/min, BP: 100/70 mm Hg, RR: 28/min, SpO2: 94 % in RA • JVP elevated • No (Pallor, Icterus, Cyanosis, Clubbing, LN, Pedal Edema) • CVS: S1S2+, No added sounds, No murmur • RS: NVBS+, B/L Basal fine crepitations + • P/A: Soft, Non-tender, No organomegaly • CNS: NFND, B/L Pupils RTL
  • 6. Investigations ECG on arrival • ST depression & T inversion in Lead II, III, aVF, V2 - V6 • ST elevation in aVR • HR: 88/min • Left Main pattern
  • 7. Investigations • Echo: • Global hypokinesia of LV • IVC diameter: 2 cm • Cardiac enzymes elevated • CT chest: Pulmonary edema • CBC, RFT, LFT, Electrolytes: Normal
  • 8. Investigations After 2 hours, when patient had a prompt pain relief but dyspnea persisted • Regression of previous ST-T changes correlating with chest pain relief
  • 9. Investigations Prior to discharge • CAG: Normal Epicardial Coronaries • Echo: Hypokinesia of LV + • ECG: Normalisation of previous ST-T changes. No significant ST-T changes now Reviewing 2 weeks after discharge • Echo: Normal LV systolic function • ECG: Normal • Symptom free
  • 10. Diagnosis • Anaphylaxis - NSAID (Diclofenac) induced • MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries) • Allergic trigger (?Vasospasm) - KOUNIS SYNDROME • Pulmonary edema (cardiogenic) - recovered
  • 11. Not a rare disease occurrence But a rarely identified one • ECG CHANGES & CHEST DISCOMFORTS THAT OCCUR IN ALLERGIC REACTIONS • Not always secondary to anaphylactic / distributive shock • Heart could be the primarily affected organ causing downstream effects • Timely identification improves outcomes