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Sinus rhythm at 82<span class="elsevierStyleHsp" style=""></span>bpm. Normal PR, narrow QRS. Generalised depression of up to 4–5<span class="elsevierStyleHsp" style=""></span>mm (V3–V6, I, II, III, aVF) with ST elevation of 1.5–2<span class="elsevierStyleHsp" style=""></span>mm in aVR and V1.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Kounis syndrome (KS) is defined as the occurrence of an acute coronary syndrome (ACS), including coronary spasm, myocardial infarction and <span class="elsevierStyleItalic">stent</span> thrombosis, in the context of a severe allergic or hypersensitivity reaction, also known as allergic angina or allergic infarction.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">KS is classified into 3 types: type I occurs in the absence of previous coronary artery disease, originating in coronary spasm in the context of acute release of inflammatory mediators with or without elevated cardiac enzymes and troponins; type II corresponds to those cases with pre-existing coronary artery disease and type III includes patients in whom coronary artery stent thrombosis occurs, with histological presence of eosinophils and mast cells.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Diagnosis is mostly clinical and requires high suspicion. The onset of allergic symptoms together with an acute coronary syndrome preceded by a possible allergic trigger is the typical clinical presentation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiopathogenic mechanism is the release of different inflammatory mediators, such as histamine, platelet activating factor, arachidonic acid products, neutral proteases and different cytokines released during mastocyte activation. Platelets are also involved in this process through the Fcγ RI, Fcγ RII, Fcε RI and Fcε RII receptors located on the surface.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the severity and complexity of presentation, most of the information published to date comes from isolated clinical cases or case series; no publications on ferric carboxymaltose have been found to date, which is why we report the case.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A 39-year-old woman presented with anaphylactic symptoms after intravenous iron carboxymaltose infusion 3<span class="elsevierStyleHsp" style=""></span>min after starting the infusion. The patient started with severe headache, abdominal pain and chest tightness along with generalised skin flushing and haemodynamic instability, consisting of oxygen saturation of 91%, decreased level of consciousness and arterial hypotension of 85/60<span class="elsevierStyleHsp" style=""></span>mmHg. Rapid administration of 200<span class="elsevierStyleHsp" style=""></span>mg of hydrocortisone, 80<span class="elsevierStyleHsp" style=""></span>mg of methylprednisolone, 5<span class="elsevierStyleHsp" style=""></span>mg of dexchlorpheniramine, 10<span class="elsevierStyleHsp" style=""></span>mg of metoclopramide and 1<span class="elsevierStyleHsp" style=""></span>mg of adrenaline was administered, requiring oxygen therapy and a subsequent new course of hydrocortisone.</p><p id="par0035" class="elsevierStylePara elsevierViewall">An electrocardiogram (ECG) was performed with generalised ST-segment depression and ST-segment elevation in aVR and V1, suggestive of left main coronary artery/multivessel involvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient was transferred to the coronary ICU. In the ED blood test, she had a high-sensitivity troponin T enzyme peak of 396<span class="elsevierStyleHsp" style=""></span>pg/mL (0−14<span class="elsevierStyleHsp" style=""></span>pg/mL), with a subsequent progressive decrease.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">After treatment administration, the patient was clinically and haemodynamically stable, with no chest pain or dyspnoea, only oropharyngeal pruritus and eyelid oedema, and normal ECG. Given the suspicion of KS, a coronary CT angiography was requested to rule out coronary artery involvement (differential diagnosis of KS type I vs. type II), showing coronary arteries without lesions and echocardiogram with normal left ventricular ejection fraction (LVEF), without associated valvular heart disease. The patient was diagnosed with NSTEMI, type I KS and anaphylactic shock after administration of intravenous iron carboxymaltose.</p><p id="par0045" class="elsevierStylePara elsevierViewall">From a cardiovascular point of view, the patient was found to be asymptomatic during her stay on the hospital ward as well as haemodynamically stable. She was assessed by allergology, with a recommendation to avoid taking iron in any of its forms and routes of administration.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The treatment of KS consists of a combination of myocardial revascularisation if necessary combined with treatment of the allergic reaction at the same time.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">High clinical suspicion is essential in young patients with no associated comorbidity or cardiovascular risk factors in the presence of ACS after administration of probably allergic agents. This is a serious and under-diagnosed disease in which rapid treatment and discontinuation of the causative agent are key to its prognosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">A literature search was carried out in the PubMed database. Firstly, using the MeSH terms “Kounis Syndrome” and “diagnosis”; “treatment”; “Allergic acute coronary syndrome”; “iron” and “ferric”, narrowing the search with the filter “Review” and “Publication date 10 years”, covering the period from 2012 to 2022. Subsequently, it was expanded with the term “Kounis Syndrome” in free text. Finally, it was completed with a third manual search in the light of certain aspects mentioned in some of the articles reviewed that were considered relevant.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0065" class="elsevierStylePara elsevierViewall">The patient was informed in detail about the publication of this case, accepting and signing the informed consent form.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">We have not received any funding for the publication of this case report.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1327 "Ancho" => 2341 "Tamanyo" => 776570 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">12-lead ECG. Sinus rhythm at 82<span class="elsevierStyleHsp" style=""></span>bpm. Normal PR, narrow QRS. Generalised depression of up to 4–5<span class="elsevierStyleHsp" style=""></span>mm (V3–V6, I, II, III, aVF) with ST elevation of 1.5–2<span class="elsevierStyleHsp" style=""></span>mm in aVR and V1.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome de Kounis, urgencia diagnóstica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Molina Anguita" 1 => "C. García Rodríguez" 2 => "Y. Méndez Díaz" 3 => "P.A. Galindo Bonilla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semerg.2015.01.002" "Revista" => array:8 [ "tituloSerie" => "Semergen." "fecha" => "2016" "volumen" => "42" "numero" => "7" "paginaInicial" => "133" "paginaFinal" => "135" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25684308" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S073510971500217X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N.G. Kounis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1515/cclm-2016-0010" "Revista" => array:7 [ "tituloSerie" => "Clin Chem Lab Med." 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Journal Information
Vol. 161. Issue 3.
Pages 130-131 (August 2023)
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Vol. 161. Issue 3.
Pages 130-131 (August 2023)
Letter to the Editor
Kounis syndrome after intravenous iron administration
Síndrome de Kounis tras administración de hierro intravenoso
Marina Jara Vidal
, María Carmen López García, Rosa Pilar Quílez Toboso
Corresponding author
Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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