# Type II Kounis syndrome triggered by iodinated contrast during coronary angioplasty: A case report and clinical insights

## TL;DR

A 57-year-old man with heart disease developed a rare allergic reaction during a heart procedure, causing severe chest symptoms and requiring immediate treatment.

## Contribution

This case report highlights Type II Kounis syndrome triggered by iodinated contrast in a patient with pre-existing coronary artery disease.

## Key findings

- The patient developed anaphylactic shock and coronary vasospasm after iodinated contrast administration.
- Tryptase levels confirmed mast cell activation, and treatment led to rapid clinical improvement.
- The case emphasizes the importance of recognizing Kounis syndrome in patients with a history of heart disease undergoing contrast procedures.

## Abstract

Kounis syndrome or “allergic angina” or “allergic myocardial infarction” is acute coronary syndrome that results from hypersensitivity reactions. It may also result from interventions involving the use of iodinated contrast media in patients with previous coronary artery disease. Early treatment and diagnosis prevent severe cardiovascular implications.

We present the case of a 57-year-old male patient with a history of ischemic heart disease who developed Type II Kounis syndrome during a scheduled coronary angioplasty. On administration of iodinated contrast (Visipaque), the patient suddenly experienced anaphylactic shock, diffuse coronary vasospasm, ST elevation, and acute left ventricular failure. Although he did not have any known history of previous allergies, the clinical presentation was consistent with acute hypersensitivity reaction superimposed on atherosclerotic disease. Immediate treatment with intravenous adrenaline, corticosteroids, antihistamines, and hemodynamic stabilization resulted in rapid clinical stabilization.

Coronary angiography was found to reveal complete reversal of coronary spasm after treatment. Follow-up laboratory tests demonstrated a stark rise in the concentration of serum tryptase during the acute attack, followed by normalization, which confirmed mast cell activation. The patient was discharged in stable condition with cardiology and allergology follow-up, including contrast allergy test.

Kounis syndrome is an uncommon but life-threatening condition to be remembered in patients with pre-existing coronary artery disease undergoing contrast-related procedures and developing features of anaphylaxis. This case report highlights the clinical presentation of Type II Kounis syndrome, and awareness and multidisciplinary approach need to be increased for optimal outcome.

•A rare but serious condition where an allergic reaction coexists with acute coronary syndrome, leading to coronary vasospasm triggered by inflammatory mediators.•A 57-year-old male with ischemic heart disease developed acute symptoms, including hypotension, skin rash, and coronary vasospasm shortly after iodine contrast injection during coronary angiography.•The patient was diagnosed with Type II Kounis Syndrome, where allergic-mediated coronary vasospasm occurred on top of pre-existing atherosclerotic coronary disease.•The patient received immediate treatment with adrenaline, corticosteroids, antihistamines, and furosemide. Coronary spasm resolved after treatment, and the patient showed significant improvement.•Tryptase levels decreased from 17 μg/L to 3.2 μg/L, confirming mast cell deactivation. Further iodine contrast allergy tests were planned to confirm the cause of the allergic reaction.

A rare but serious condition where an allergic reaction coexists with acute coronary syndrome, leading to coronary vasospasm triggered by inflammatory mediators.

A 57-year-old male with ischemic heart disease developed acute symptoms, including hypotension, skin rash, and coronary vasospasm shortly after iodine contrast injection during coronary angiography.

The patient was diagnosed with Type II Kounis Syndrome, where allergic-mediated coronary vasospasm occurred on top of pre-existing atherosclerotic coronary disease.

The patient received immediate treatment with adrenaline, corticosteroids, antihistamines, and furosemide. Coronary spasm resolved after treatment, and the patient showed significant improvement.

Tryptase levels decreased from 17 μg/L to 3.2 μg/L, confirming mast cell deactivation. Further iodine contrast allergy tests were planned to confirm the cause of the allergic reaction.