Recurrent cardiac arrests caused by Kounis syndrome without typical allergic symptoms

Published:October 27, 2022DOI:


      Kounis syndrome is a rare disease in which coronary spasm or acute coronary syndrome is induced by type I allergy. Concurrence of allergic reaction and chest pain are important clues to establish diagnosis. We report a rare case of Kounis syndrome without obvious signs of allergy.
      A 52-year-old woman experienced abdominal pain followed by ventricular fibrillation (VF) storm. Ten months earlier, the patient underwent subcutaneous implantable cardioverter-defibrillator implantation based on the previous diagnosis of idiopathic VF. In both episodes, the patient was given dental treatment and administered loxoprofen before VF onset. After we performed loxoprofen provocation test, electrocardiogram revealed ST-segment elevation in leads II, III, and aVF. Moreover, the patient developed VF again. An emergency coronary angiography after recovery showed no significant findings. However, myocardial scintigraphy presented a perfusion-metabolism mismatch in the inferior wall. Furthermore, laboratory test results after provocation revealed increased histamine level. Based on these findings, we diagnosed the patient with Kounis syndrome.
      Kounis syndrome without typical allergic symptoms is challenging to diagnose. Therefore, suspecting the possibility of allergic reactions and detailed history taking are important, particularly when confronted with recurrent coronary spasm, acute coronary syndrome, and inexplicable cardiac arrest.

      Learning objective

      Kounis syndrome is a rare coronary disease with vasospasm or plaque rupture, induced by type I allergy. Since Kounis syndrome without typical allergic symptoms is challenging to diagnose, a high index of suspicion is necessary. Detailed history taking can provide important clues to establish diagnosis, particularly when confronted with recurrent coronary spasm, acute coronary syndrome, and inexplicable cardiac arrest.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiology Cases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kounis N.G.
        Coronary hypersensitivity disorder: the kounis syndrome.
        Clin Ther. 2013; 35: 563-571
        • Giovannini M.
        • Koniari I.
        • Mori F.
        • Barni S.
        • Novembre E.
        • Kounis N.G.
        Kounis syndrome: towards a new classification.
        Int J Cardiol. 2021; 341: 13-14
        • Renda F.
        • Landoni G.
        • Trotta F.
        • Piras D.
        • Finco G.
        • Felicetti P.
        • Pimpinella G.
        • Pani L.
        Kounis syndrome: an analysis of spontaneous reports from international pharmacovigilance database.
        Int J Cardiol. 2016; 203: 217-220
        • Kounis N.G.
        Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management.
        Clin Chem Lab Med. 2016; 54: 1545-1559
        • Akoz A.
        • Tanboga H.I.
        • Emet M.
        • Bayramoglu A.
        • Kizrak Y.
        • Kantarci M.
        • Aslan S.
        A prospective study of kounis syndrome: clinical experience and cardiac magnetic resonance imaging findings for 21 patients.
        Acta Medica Mediterranea. 2013; 29: 811-816
        • Ginsburg R.
        • Bristow M.R.
        • Stinson E.B.
        • Harrison D.C.
        Histamine receptors in the human heart.
        Life Sci. 1980; 26: 2245-2249
        • Toda N.
        Mechanism of histamine actions in human coronary arteries.
        Circ Res. 1987; 61: 280-286
        • Okumura K.
        • Yasue H.
        • Matsuyama K.
        • Matsuyama K.
        • Morikami Y.
        • Ogawa H.
        • Obata K.
        Effect of H1 receptor stimulation on coronary artery diameter in patients with variant angina: comparison with effect of acetylcholine.
        J Am Coll Cardiol. 1991; 17: 338-345
        • Matsuyama K.
        • Yasue H.
        • Okumura K.
        • Matsuyama K.
        • Ogawa H.
        • Morikami Y.
        • Inotsume N.
        • Nakano M.
        Effects of H1-receptor stimulation on coronary arterial diameter and coronary hemodynamics in humans.
        Circulation. 1990; 81: 65-71