CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 256 AFRICA Case Report Kounis syndrome caused by bee sting: a case report and literature review Wen-Juan Lin, Yue-qing Zhang, Zhen Fei, Dan-dan Liu, Xing-Hang Zhou Abstract Kounis syndrome is defined as an acute coronary syndrome (ACS) secondary to allergic or hypersensitivity reactions. It can be further categorised into subtypes such as coronary vasospasms, acute myocardial infarction or stent thrombosis based on the pathogenesis. Kounis syndrome is most likely an underdiagnosed condition in China, given the many triggers reported in the literature. Herein, we report a case of Kounis syndrome, possibly triggered by a bee sting. The patient had late onset of angina symptoms with delayed diagnosis due to unfamiliarity with this condition. In patients with clinical signs of ACS that are superimposed on a hypersensitivity reaction, especially those with pre-existing cardiovascular risk factors, Kounis syndrome should be considered, so that appropriate assessment and treatment can be initiated. Prompt management of both the allergic reaction and the ACS is vital for Kounis syndrome. Keywords: Kounis syndrome, China, bee sting Submitted 13/12/21; accepted 3/8/22 Published online 29/8/22 Cardiovasc J Afr 2023; 34: 256–259 www.cvja.co.za DOI: 10.5830/CVJA-2022-042 It is well known that cardiovascular symptoms can arise after allergic, hypersensitivity, anaphylactic or anaphylactoid reactions. The first report of acute myocardial infarction after urticaria associated with penicillin use was published in 1950.1 However, it was not until 1991 that the term allergic angina syndrome or Kounis syndrome was proposed to describe the occurrence of an acute coronary syndrome (ACS), that is, angina and myocardial infarction, as a result of endothelial dysfunction secondary to allergic reaction. These ACS events may occur in the form of coronary spasms, acute myocardial infarction or stent thrombosis.2 Kounis syndrome has been reported in different ethnic and age groups (from two- to 90-year-olds) and geographic locations. Available data suggest that Kounis syndrome might not be a rare disease but is under reported in the literature due to being missed or undiagnosed in clinical practice. As far as China is concerned, there are only a few case reports so far concerning this entity. Besides, in the majority of cases, the time between trigger event and symptom onset is usually within one hour, which is not surprising given the nature of the acute immune response. Herein, we report a case of Kounis syndrome, possibly triggered by a bee sting. However, the patient had late onset of angina symptoms with delayed diagnosis due to unfamiliarity with this condition. Therefore, this case should raise awareness of the existence of Kounis syndrome, especially for physicians practicing at primary care facilities in China. Case report A 42-year-old male was referred to our emergency department (ED) with a three-day duration of progressively worsening retrosternal chest pain following upper limb joint pain, and a reddish swollen skin area behind the right ear that had occurred after a bee sting. His past medical history included poorly controlled hypertension for 10 years, being a smoker of more than 40 pack-years, and an allergy to insects on skin contact. The initial bee sting happened in the morning and was behind the right ear, which caused local skin allergic reactions of tenderness, redness and swelling (1 × 1 cm) and he stated he had removed the stinger by himself (day one). The next morning, he developed bilateral shoulder and elbow joint pain, which was aggravated by movement. The swollen skin area also increased to 3 × 3.5 cm. Later the same day (34 hours after the sting), he started to have retrosternal cardiac type chest pain, which gradually worsened, with accompanied diaphoresis. He consulted a local general practitioner on day four (about 36 hours after onset of chest pain) who recorded high blood pressure (260/160 mmHg) and T-wave inversion in the inferior leads on electrocardiogram (ECG) (Fig. 1A). He was prescribed metoprolol and nifedipine and urgently referred to a local hospital ED the same day, where laboratory investigations showed high glucose (27.30 mmol/l) and elevated high-sensitivity troponin I (hsTnI) levels (155.9 ng/l, reference range 0–40) (Fig. 2). Department of Cardiology, The First Affiliated Hospital of Zhejiang University, Hangzhou, China Wen-Juan Lin, MNurs, linwenjuan2021@163.com Yue-qing Zhang, BNurs Zhen Fei, BNurs Department of Cardiology, Changxing Hospital of Traditional Chinese Medicine, Huzhou, China Dan-dan Liu, MD Department of Internal Medicine, Hengdian Hospital, Dongyang, China Xing-Hang Zhou, MD
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