Cardiovascular Journal of Africa: Vol 24 No 2 (March 2013)

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CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 2, March 2013 e10 AFRICA
Kounis syndrome secondary to simultaneous oral
amoxicillin and parenteral ampicillin use in a young man
TAHIR BEZGIN, ÇETIN GEÇMEN, BIROL ÖZKAN, GÖKHAN ALICI, MEHMET EMIN KALKAN,
RAMAZAN KARGIN, ALI METIN ESEN
Abstract
The concurrence of acute coronary syndrome with allergy
or hypersensitivity as well as with anaphylactic or anaphy-
lactoid reactions is increasingly encountered in daily clini-
cal practice. There are several reports associating mast cell
activation with acute cardiovascular events in adults. This
was first described by Kounis as ‘allergic angina syndrome’,
progressing to ‘allergic myocardial infarction’. The main
mechanism proposed is the vasospasm of coronary arteries.
We present a case of a 28-year-old man who was admit-
ted to our hospital with thoracic pain and dyspnoea. The
symptoms recurred after simultaneous use of 1 g amoxicillin/
clavulanic acid orally and 1 g ampicillin/sulbactam parenter-
ally for tonsillitis the night before presentation and on the
morning of admission.
Keywords: Kounis syndrome, allergic MI, penicilline-induced
acute coronary syndrome
Submitted 8/5/12, accepted 23/10/12
Published online 13/11/12
Cardiovasc J Afr 2013; 24: e10–e12
DOI: 10.5830/CVJA-2012-077
Allergic angina and allergic myocardial infarction, referred
as Kounis syndrome (KS), have gained acceptance as a cause
of coronary artery spasm. Kounis and Zavras1 described the
‘syndrome of allergic angina’ as the coincidental occurrence
of chest pain and allergic reactions, accompanied by clinical
and laboratory findings of classical angina pectoris caused by
inflammatory mediators released during the allergic insult.
Causes of KS2 include drugs (antibiotics, analgesics,
antineoplastics, contrast media, corticosteroids, intravenous
anesthetics, non-steroidal anti-inflammatory drugs, skin
disinfectants, thrombolytics, anticoagulants), various conditions
(angio-oedema, bronchial asthma, urticaria, food allergy,
exercise-induced allergy, mastocytosis, serum sickness) and
environmental exposure (stings of ants, bees, wasps and jellyfish,
grass cuttings, millet allergy, poison ivy, latex contact, eating
shellfish, viper venom poisoning).
KS due to penicillin use is rare in adults. Its appearance,
caused by the simultaneous use of these agents both parenterally
and orally, may be even rarer, and it has not been reported before.
Such was the case in a young man, to be described below.
Case report
A 29-year-old male patient was admitted to the emergency
department with symptoms of dyspnoea and severe squeezing
chest pain. The symptoms had occurred the night before
presentation and had recurred that morning. The patient had had
an intramuscular injection of 1 g ampicillin sulbactam and 1 g
oral amoxicillin clavulanate 30 min before each episode, for an
upper respiratory tract infection.
His history was unremarkable for any allergic reaction,
hy­pertension, diabetes mellitus or dyslipidaemia. He was a
non-smoker. Lung sounds were clear, and no murmurs, rubs or
extra sounds were found on cardiac auscultation.
The physical examination revealed blood pressure of 110/80
mmHg, a regular pulse of 81 beats/min, and oxygen saturation of
92%. He did not have pruritus or a rash. Initial and subsequent
ECGs showed sinus rhythm and slight ST-segment elevation in
the inferior leads (Fig. 1).
The patient’s laboratory findings, taken in the emergency
room, were as follows: haemoglobin 12.7 g/dl, leukocytes 11 700/
μl, eosinophil count 0.04 (in the normal range), troponin I: 29 ng/
ml, creatinine kinase (CK) 2 116 U/l, and CK-MB isoenzyme 101
U/l). Serum tryptase and IgE levels were not determined.
He was given 5 mg morphine sulfate, 25 mg prednisolone,
50 mg of diphenydramine and 50 mg of ranitidine intravenously.
On this treatment the retrosternal pain and dyspnoea started to
improve. Transthoracic echocardiography revealed normal left
ventricular systolic functions and no segmentary wall-motion
abnormality. An emergency coronary angiogram was performed
and showed normal coronary arteries (Fig. 2 A-B, Movie 1-2).
His recovery was uneventful and he was discharged on his
third day of hospitalisation. On prick-skin testing for B-lactams,
a strongly positive result to penicillin was noted after discharge.
Discussion
Development of acute coronary syndrome after exposure to an
al­lergic insult is an unexpected and rarely reported phenomenon.
Cardiology Clinic, Kartal Koşuyolu Heart and Research
Hospital, Istanbul, Turkey
TAHIR BEZGIN, MD,
ÇETIN GEÇMEN, MD
BIROL ÖZKAN, MD
GÖKHAN ALICI, MD
MEHMET EMIN KALKAN, MD
RAMAZAN KARGIN, PhD
ALI METIN ESEN, PhD
Case Report