To the Editor,
We thank you for the interest in and positive reviews for our case report published in the Anatolian Journal of Cardiology entitled “Bonsai-induced Kounis Syndrome in a young male patient” (1).
The most important step of the diagnosis of Kounis syndrome is determining the presence of allergic symptoms accompanying chest pain. Systemic allergic reaction is manifest with skin, mucosa, respiratory system, cardiovascular system, or gastrointestinal system signs in minutes/hours after exposure to the allergen. The clinical picture is variable in a wide spectrum from mild skin lesions that might be unnoticed to anaphylactic shock. The course of the allergic reaction occurring in this case was chest pain without skin involvement. No skin lesion was encountered in this patient. However, skin lesions may be absent in majority of the cases (2). The patient was questioned and examined for skin lesions; nevertheless, the mild nature of the skin lesions should be considered so that they may be unnoticeable (3). Leukocytosis, eosinophilia, and increased IgE levels were detected in this case, and other tests could not be performed because of technical unavailability. The skin prick test may be helpful in diagnosis; however, its rate of usage is found to be low in the literature (4).
Primary treatment of Kounis syndrome is AKS management and suppression of the allergic reaction. Because the primary mechanism is coronary vasospasm in young and otherwise healthy patients who have no risk factors for coronary artery disease and are considered to have Type I variant Kounis syndrome, the first-line treatment is nitrates and calcium channel blockers. Suppression of allergy by steroids and antihistamines alone may even alleviate coronary vasospasm. AKS management in those patients, on the other hand, is unclear. Debatable applications have been reported, particularly on the antiaggregants. Because aspirin is a basic building block treatment in the management of AKS, we started aspirin (5). However, as you have mentioned, aspirin has the potential to increase the continuing allergic reaction in patients with Kounis syndrome. It may be more suitable to prefer clopidogrel in patients with hypersensitivity to aspirin.
References
- 1.İnci S, Aksan G, Doğan A. Bonsai-induced Kounis Syndrome in a young male patient. Anatol J Cardiol. 2015;15:952–3. doi: 10.5152/AnatolJCardiol.2015.6641. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Tok D, Özcan F, Şentürk B, Gölbaşı Z. A case of acute coronary syndrome following the use of parenteral penicillin:Kounis syndrome. Turk Kardiyol Dern Ars. 2012;40:615–9. doi: 10.5543/tkda.2012.54077. [DOI] [PubMed] [Google Scholar]
- 3.Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol. 2004;114:371–6. doi: 10.1016/j.jaci.2004.04.029. [DOI] [PubMed] [Google Scholar]
- 4.Ralapanawa DM, Kularatne SA. A case of Kounis syndrome after a hornet sting and literature review. BMC Res Notes. 2014;7:867. doi: 10.1186/1756-0500-7-867. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. ESC Committee for Practice Guidelines. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC) Eur Heart J. 2016;14:267–315. doi: 10.1093/eurheartj/ehv320. [DOI] [PubMed] [Google Scholar]