Korean Circ J.  2013 Aug;43(8):561-564. 10.4070/kcj.2013.43.8.561.

Kounis Syndrome Presenting as Very Late Stent Thrombosis in an Everolimus-Eluting Stent Following Wasp Stings

• Min JH
• Kang MH

• KMID: 2224847
• DOI: http://doi.org/10.4070/kcj.2013.43.8.561

Abstract

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation following an allergic insult. We report a 56-year-old man who experienced a ST-segment elevation myocardial infarction after wasp stings. The patient presented without signs of anaphylaxis or shock. Coronary angiography showed an everolimus-eluting stent thrombosis (ST) of the left anterior descending artery occluding the vessel completely which was deployed for stable angina 3 years ago. The patient had been compliant with anti-platelet therapy, and no relevant cardiovascular events occurred until the day of admission. We interpreted our patient's condition as a manifestation of Kounis syndrome. To our knowledge, this is the first case of Kounis syndrome showing very late ST in a second-generation drug-eluting stent caused by wasp stings.

Keyword

Hypersensitivity; Drug-eluting stent; Thrombosis; Acute coronary syndrome

MeSH Terms

Acute Coronary Syndrome
Angina, Stable
Bites and Stings
Coronary Angiography
Drug-Eluting Stents
Humans
Hypersensitivity
Mast Cells
Middle Aged
Myocardial Infarction
Sirolimus
Stents
Thrombosis
Wasps
Everolimus
Glycosaminoglycans
Sirolimus

Figure

• 

  Fig. 1 Electrocardiogram showing ST-segment elevation in the anterior leads and reciprocal ST-segment depression in the inferior leads at presentation.

• 

  Fig. 2 Coronary angiography of the left coronary artery. A: coronary angiography showing stent thrombosis occluding the left anterior descending artery completely. B: a new drug-eluting stent was deployed with a good angiographic result.

Reference

1. Kounis NG. Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm? Int J Cardiol. 2006; 110:7–14.

2. Biteker M. Current understanding of Kounis syndrome. Expert Rev Clin Immunol. 2010; 6:777–788.

3. Tsigkas G, Chouchoulis K, Theodoropoulos K, Kounis NG, Alexopoulos D. Allergic reaction reveals a non-lethal late stent thrombosis. A new subtype of Kounis syndrome? Int J Cardiol. 2011; 149:281–282.

4. Kogias JS, Papadakis EX, Tsatiris CG, et al. Kounis syndrome: a manifestation of drug-eluting stent thrombosis associated with allergic reaction to contrast material. Int J Cardiol. 2010; 139:206–209.

5. Venturini E, Magni L, Kounis NG. Drug eluting stent-induced Kounis syndrome. Int J Cardiol. 2011; 146:e16–e19.

6. Horjeti B, Meco S. Late stent thrombosis or Kounis syndrome? Int J Cardiol. 2011; 150:e70–e72.

7. Siddiqi OK, Faxon DP. Very late stent thrombosis: current concepts. Curr Opin Cardiol. 2012; 27:634–641.

8. Kounis NG, Grapsas ND, Goudevenos JA. Unstable angina, allergic angina, and allergic myocardial infarction. Circulation. 1999; 100:e156.

9. Chen JP, Hou D, Pendyala L, Goudevenos JA, Kounis NG. Drug-eluting stent thrombosis: the Kounis hypersensitivity-associated acute coronary syndrome revisited. JACC Cardiovasc Interv. 2009; 2:583–593.

10. Virmani R, Guagliumi G, Farb A, et al. Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent: should we be cautious? Circulation. 2004; 109:701–705.

11. Kasim S, AbuBakar R, McFadden E. Anaphylaxis from Wasp Stings Inducing Coronary Thrombus. Cardiology. 2012; DOI: 10.1155/2012/701753.

12. Valla M, Moulin F, Angioi M, Groben L, Sadoul N, Aliot E. Myocardial infarction in a 45-year-old man following an anaphylactic reaction to a wasp sting. Int J Cardiol. 2011; 148:e63–e65.

13. Kogias JS, Sideris SK, Anifadis SK. Kounis syndrome associated with hypersensitivity to hymenoptera stings. Int J Cardiol. 2007; 114:252–255.

14. Karasu E, Minareci K. Myocardial infarction following a bee sting: an example of Type II Kounis syndrome. Int J Cardiol. 2011; 148:382–384.

15. Greif M, Pohl T, Oversohl N, Reithmann C, Steinbeck G, Becker A. Acute stent thrombosis in a sirolimus eluting stent after wasp sting causing acute myocardial infarction: a case report. Cases J. 2009; 2:7800.

16. Jackson CE, Dalzell JR, Hogg KJ. Epinephrine treatment of anaphylaxis: an extraordinary case of very late acute stent thrombosis. Circ Cardiovasc Interv. 2009; 2:79–81.

17. King SB 3rd, Smith SC Jr, Hirshfeld JW Jr, et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol. 2008; 51:172–209.

18. Joner M, Nakazawa G, Finn AV, et al. Endothelial cell recovery between comparator polymer-based drug-eluting stents. J Am Coll Cardiol. 2008; 52:333–342.

19. Stone GW, Rizvi A, Newman W, et al. Everolimus-eluting versus paclitaxel-eluting stents in coronary artery disease. N Engl J Med. 2010; 362:1663–1674.

20. Leon MB, Nikolsky E, Cutlip DE, et al. Improved late clinical safety with zotarolimus-eluting stents compared with paclitaxel-eluting stents in patients with de novo coronary lesions: 3-year follow-up from the ENDEAVOR IV (Randomized Comparison of Zotarolimus- and Paclitaxel-Eluting Stents in Patients With Coronary Artery Disease) trial. JACC Cardiovasc Interv. 2010; 3:1043–1050.