CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 9/10, October/November 2013
e12
AFRICA
Case Report
Kounis syndrome leads to cardiogenic shock
KUAI-LE CHANG, JIU CHEN, JUN YU, XIAO-LIANG DOU
Abstract
Kounis syndrome has been defined as an acute coronary
syndrome that manifests as unstable vasospastic or non-
vasospastic angina, and even as acute myocardial infarction.
It is triggered by the release of inflammatory mediators
following an allergic insult or patient ill health, drug intake
or environmental exposure. We report on a patient who
was admitted to our hospital and diagnosed with unstable
angina or acute myocardial infarction – according to analyti-
cal parameters, electrocardiographic abnormalities, and/or
coronary angiography – in the context of progesterone as
inducing factor. The results of a laboratory study revealed
electrocardiogram changes, and increased myocardial
enzymes, IgE antibodies and eosinophils. The patient experi-
enced recurring chest pain, acute myocardial infarction, and
cardiogenic shock after taking progesterone capsules; her
medication history of progesterone clearly correlated with
the onset of chest pain, which suggested that the cause of the
vasospasm may have been related to progesterone use. We
did not include patients with a history of bronchial asthma
or allergic constitution. Nevertheless, the case suggests there
is a correlation between Kounis syndrome and progesterone
as inducing factor.
Keywords:
Kounis syndrome, cardiogenic shock, anaphylaxis,
acute myocardial infarction, coronary vasospasm, progesterone
Submitted 26/4/13, accepted 25/10/13
Cardiovasc J Afr
2013;
24
: e12–e16
DOI: 10.5830/CVJA-2013-075
Kounis syndrome, also known as allergic angina syndrome, was
described in 1991 by Kounis and Zafras
1
as ‘the coincidental
occurrence of chest pain and allergic reactions accompanied by
clinical and laboratory findings of classic angina pectoris caused
by inflammatory mediators released during the allergic insult’.
They named the progression from chest pain to acute myocardial
infarction ‘allergic myocardial infarction’.
2,3
This heart condition occurs in a considerable number of
patients during episodes of anaphylaxis,
4
and frequently in
patients with prior coronary artery disease, although it has
also been observed in patients with healthy coronary vessels.
Vasospasm of the coronary arteries has been suggested to be
the main pathophysiological mechanism.
5
Knowing more about
the pathogenesis of Kounis syndrome will provide a detailed
understanding of such patients and may help to establish
rehabilitation procedures along those lines. We report on a patient
with Kounis syndrome due to taking progesterone medication.
Case report
A 37-year-old woman was admitted to the hospital for paroxysmal
retrosternal chest pain that had persisted for six months and had
intensified over the previous five hours. The patient was a
civil servant and had a body mass index of 18 kg/m
2
. She had
experienced recurring retrosternal chest pain over the previous
six months without any obvious cause. The painful episodes
lasted approximately five to 10 minutes and typically occurred
in the afternoon or at night, never in the morning. The pain could
be relieved with rest.
The patient had visited other hospitals for the symptoms but
no abnormality was found on electrocardiography (ECG) (Fig.
1), echocardiography or chest X-ray. The patient was diagnosed
with reflux oesophagitis but the intermittent use of enteric-
coated omeprazole tablets did not alleviate the pain. One month
prior to admission, the chest pain became aggravated and began
to occur more frequently, two to three times per week. The
episodes of pain occurred between 16:00 and 23:00 and lasted
from several minutes to half an hour before remitting. The pain
was not correlated with physical activities or accompanied by
referred pain. If the pain affected sleeping at night, the use of
omeprazole tablets relieved the pain and promoted sleep.
Three days prior to admission, the chest pain occurred
frequently after excessive labour and was accompanied by cold
sweating. The pain occurred two to three times a day, and each
episode lasted between 10 minutes and one hour, primarily after
dinner or before bedtime. Five hours prior to admission, the chest
pain became aggravated and was accompanied by dizziness, cold
sweats, chest tightness and shortness of breath. The patient was
admitted to the emergency room and hospitalised.
The patient had no medical or family history of hypertension,
diabetes or coronary heart disease, and she had no history
of smoking or alcohol abuse. She had a history of bronchial
asthma that had persisted for more than 10 years, but the
condition had been well controlled for four years by inhaling
salmeterol xinafoate and fluticasone propionate powder (one
puff/day). When the patient experienced an irregular menstrual
cycle and reduced menstrual flow six months earlier, she began
Department of Cardiology, 3rd Hospital of the Chinese
People’s Liberation Army, 45 Dongfeng Road, Baoji,
Shaanxi Province, China
KUAI-LE CHANG, MD,
JUN YU, MD
Centre for Mental Disease Control and Prevention, 3rd
Hospital of the Chinese People’s Liberation Army, Baoji,
Shaanxi Province, China
JIU CHEN, MD
XIAO-LIANG DOU, MD
