Clinical Images

Kounis Syndrome: Kill Two Birds WithOne Stone
Takehiro Yamashita, MD, PhD; Yasunori Oguma, MD, PhD; Nicholas G. Kounis, MD, PhD

J INVASIVE CARDIOL 2021;33(11):E920-E921.

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Key words: allergy, cefazolin, Kounis syndrome, ST change, two variants

Figure 1. Baseline coronary angiography. (A) Right coronary artery (RCA). (B) Left coronary artery (LCA).

A 59-year-old man with a 95% stenosis in his diagonalbranch (Figure 1) and no stenosis in the right coronary artery(RCA) or left circumflex artery was scheduled for percutaneous
coronary intervention. A balloon angioplasty followed by adrug-coated balloon application achieved an acceptable result(Figure 2A, 2B). After prophylactic intravenous cefazolin
administration for Proglide-site infection prevention, hestarted feeling general itching with palmar and cheek redness
without any hemodynamic compromise, which resulted inmethylprednisolone administration. However, ST elevation
appeared in the inferior leads (Figure 3B), suggesting a
potential RCA spasm. From these circumstances, a diagnosisof type I Kounis syndrome (KS) was made. Despite 2 puffs ofnitroglycerin, the ST elevation persisted when bradycardia
and hypotension progressed, resulting in his unconsciousE920

ness. While giving him intravenous epinephrine to maintainhis hemodynamics, the ST level recovered, and he became
fully conscious. When he complained of chest pain, a new ST
elevation was noticed in the lateral leads, with ST levels in
the inferior leads turning into depression (Figure 3C). Repeat
angiography demonstrated neither spasm nor occlusion in theRCA (not shown), while the diagonal branch was completelyoccluded at the proximal portion (Figure 2C), which wasconsidered to be responsible for ST elevation in the lateralleads. At that point, a diagnosis of type II KS was made. A
drug-eluting stent implantation successfully restored bloodflow (Figure 2D) and electrocardiographic changes returned
to baseline (Figure 3D). Subsequently, his intradermal test
was positive for cefazolin. This is the first reported case thatcombined 2 variants of KS in a single event.
Journal of Invasive Cardiology

YAMASHITA, et al.

sKounis Syndrome: Kill Two Birds With One Stone

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Figure 2. Percutaneous coronary intervention. (A, B, C) Balloon angioplasty followed by drug-coated balloon application achieved an acceptable result.
(D) After possible RCA spasm, drug-eluting stent implantation successfully restored blood flow.

Figure 3. (A) Electrocardiogram. (B) ST elevation appeared in the inferior leads, suggesting a potential RCA spasm. (C) New ST elevation was noticed in
the lateral leads, with ST levels in the inferior leads turning into depression. (D) After PCI, electrocardiogram returned to normal.
From the 1Department of Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan; 2Department of Cardiology, University of Patras School of Medicine, Patras, Greece.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted June 26, 2021.
The authors report patient consent for the images used herein.
Address for correspondence: Takehiro Yamashita, MD, PhD, FACC, Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, 2-1-16-1, Miyanosawa, Nishiku, Sapporo, Hokkaido 063-0052,
Japan. Email: t_yamashita@cvc-ohno.or.jp

Vol. 33 · no. 11 November 2021

E921