Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy

Abstract

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called ‘Kounis-like’ syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.

Resumen

La anafilaxis es un síndrome multisistémico agudo grave que implica la liberación masiva del torrente sanguíneo de mastocitos y mediadores basófilos. Cuando las arterias coronarias son el objetivo principal, se puede sospechar el síndrome de Kounis o, más raramente, el llamado síndrome de Kounis cuando se trata de arterias cerebrales. Las lesiones isquémicas cerebrales pueden resultar de una presión arterial baja o de una acción mediadora proinflamatoria y/o vasoconstrictora directa en el sistema arterial cerebral. El diagnóstico es difícil en pacientes anestesiados. El tratamiento también es un reto, ya que la administración de adrenalina puede empeorar la isquemia.

Presentamos un caso de síndrome de Kounis tipo II inducido por amoxicilina-ácido clavulánico bajo anestesia general, complicado con encefalopatía grave e irreversible de origen isquémico.