A Rare Presentation of Kounis Syndrome Induced by Echocardiography Contrast

Kounis syndrome is an inflammatory-mediated allergic response that manifests with clinical signs of acute coronary syndrome. This reaction can be precipitated by common triggers in patients atopy such as food, environmental allergens, and contrast agents (1)Kounis NG. Coronary hypersensitivity disorder: the Clin Ther. 2013;35(5):563-571.Google Scholar). uncommon phenomenon challenging to diagnose due overlapping symptoms vasospasm. Early diagnosis crucial ensure offending agent quickly discontinued. We present a case brought upon administration sulfur hexafluoride lipid-type microspheres (SHLTAM), used certain echocardiographic studies during workup atypical cardiac symptoms. A 51-year-old man presented chest pain, dyspnea, dizziness, heaviness, diaphoresis started after working outside for extended period. His past medical history was notable artery disease, hypertension, active cocaine use, heart failure reduced ejection fraction, left ventricular (LV) thrombus on warfarin subtherapeutic INR. There no reported nor documented allergy including products. most recent heath catheterization three months prior admission showed patent stents obtuse marginal (OM), anterior descending (LAD) right (RCA). On physical exam, he afebrile, breathing comfortably room air, distress. Initial electrocardiogram (EKG) sinus rhythm minimal anterolateral ST depressions intraventricular conduction delay (Supplementary Figure S1), consistent findings previous EKGs. Laboratory evaluation significant elevated high sensitivity troponin 62 ng/L, creatinine 3.3 mg/dL (baseline 0.9-1.1 mg/dL), BUN 51 mg/dL, CK 120 U/L. Urine toxicology report positive cocaine. The patient subsequently admitted further work-up treatment kidney injury. patient’s troponins trended down over next 16 hours, decreasing 31.9 ng/L 29.0 ng/L. day two admission, transthoracic echocardiography (TTE) SHLTAM obtained surveillance LV compared his baseline echo from four hospitalization (Video 1a-1c). study fraction 40-45%. diagnosed echocardiogram before admission. Shortly contrast, rapid called tachypnea, hypotension, mouth swelling, 10/10 pain sternal area, decreased responsiveness. Focused examination identified diffuse confluent urticarial rash, edematous lips tongue, paradoxical wheezing heard auscultation. EKG elevations leads V2-V3 (Figure 1) 82.9 Complete blood count differential did not show eosinophil counts or contrast. Epinephrine, Solumedrol, Benadryl were administered suspected anaphylaxis heparin drip restarted. Repeat fifteen minutes later resolution changes S2). anaphylactic event 65.3 Given initial EKG, taken urgent catheterization. Left revealed LAD, OM first branch, RCA addition non-obstructive disease Video S1a-S1b). weren’t any occlusions could account episode. follow-up TTE one 45-50%, mildly enlarged wall thickness, thrombus. Upon discharge, antihypertensive switched lisinopril losartan prophylactic measure against potential bradykinin reactions ACE inhibitor usage. He followed up cardiology weeks discharge reportedly doing well. No care medications made at visit counselled permanent cessation Anaphylactic segment following exposure (Lumason®) clinically rare allergic-mediated disorder has been current date different variants: vasospastic angina, myocardial infarction, stent thrombosis Antibiotics insect bites commonly induce across literature many other bean ingestion, anesthetic regimens, vaccines (2)Memon S. Chhabra L. Masrur Parker M.W. Allergic (Kounis syndrome).Proc (Bayl Univ Med Cent). 2015; 28: 358-362Crossref PubMed Google review our allergenic reveal incidence sulfur-containing molecules. five years initiated new within six hospitalization. Furthermore, this third SHALTAM Contrast various imaging modalities rarely syndrome; Shibuya et al., ten cases associated media since 1991 (3)Shibuya K. Kasama Funada R. Katoh H. Tsushima Y. induced media: literature.Eur J Radiol Open. 2019; 6: 91-96Abstract Full Text PDF Scopus (10) included iopromide, iohexol, gadoterate meglumine, iopamidol. single-center Netherlands adverse events (SonoVue), widely Europe, only 0.9% 352 four-year period (4)Geleijnse M.L. Nemes A. Vletter W.B. al.Adverse use sulphur (SonoVue) agent.J Cardiovasc (Hagerstown). 2009; 10: 75-77Crossref (0) paucity may explain why early accurate incredibly setting. Despite similar seen syndrome, main goal effectively terminating antihistamines, corticosteroids, epinephrine. Once control achieved, standard implemented. decision pursue controversial setting symptoms; however, often compel clinicians definitively rule out Although vast majority are secondary vasospasm subtype required exclude motion changes. In retrospective analysis evaluating 78,383 doses perflutren, developed anaphylactic-like perflutren (5)Wei Mulvagh S.L. Carson al.The safety deFinity Optison ultrasound image enhancement: doses.J Am Soc Echocardiogr. 2008; 21: 1202-1206Abstract (197) indicative very safe profile low risk reactions. Treatment carries provoking fatal arrhythmia. Epinephrine’s activation alpha-adrenoreceptors way its effect hepatic calcium-dependent potassium channels cause sharp decrease plasma levels (6)Brown M.J. Brown D.C. Murphy M.B. Hypokalemia beta2-receptor stimulation circulating epinephrine.N Engl Med. 1983; 309: 1414-1419Crossref Severe hypokalemia well-known tachyarrhythmias, particularly tachycardia fibrillation. augmented who cocaine, potent vasoconstrictor also lower predispose users arrhythmias. Our tested days receiving contrast; therefore, illicit substance response. However, cocaine’s metabolite half-life approximately hours confers probability amount body event. Per hospital policy, permitted leave process complete exceptions those under comfort orders advice. stringently enforced use. Therefore, it highly unlikely would have able obtain hospitalized. inpatient outpatient settings steadily increasing given broad spectrum detecting myocardial-related pathologies. occasionally enhance opacification, especially stress testing. infrequent agents, awareness regarding their ingredients cross-reactivity absent among clinicians. SHLTAM, example, contains ingredient which trigger sulfonamide allergies. Perflutren implicated when polyethylene glycol (an found laxatives colonoscopy bowel preparations) eleven (7)FDA Warns Against Some Ultrasound Agents Patients PEG Allergy. www.acr.org. Accessed February 4, 2023. https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-April-24-2021-Issue/FDA-Warns-Against-Some-Ultrasound-Contrast-Agents#:∼:text=The%20federal%20Food%20and%20DrugGoogle As result, FDA issued official warning glycol. aftermath there change protocol facility safety. All echocardiograms now performed perflutren.•Sulfur Hexafluoride Lipid-Type Microspheres vasospasm•Consider lipid type-a case. While material, should consider if necessary, switching safer profiles.