Recurrent Kounis syndrome. How should be the long-term treatment of Kounis syndrome?

Abstract

A 45-year-old female patient presented to the emergency room complaining of retrosternal chest pain and weakness accompanied by sweating that began after a bee sting and lasted for approximately half an hour. The patient was conscious, and she had pale and sweaty appearance. Arterial blood pressure was 70/50 mm Hg, pulse was 56 rpm, and oxygen saturation was 96%. The patient denied any complaints such as itching or skin problems that could be associated with an allergic reaction. The electrocardiogram showed ST elevation in DII, DIII, and aVF, and reciprocal changes in anterior leads. Transthoracic echocardiography showed hypokinesia in the inferior wall. It was realized from her past history that the patient had been admitted to a hospital one year prior with the same complaints following a bee string, after which she underwent coronary angiography with the diagnosis of acute myocardial infarction that revealed normal coronary arteries. She had been told that acute myocardial infarction was due to the bee sting (Kounis syndrome) and was discharged from the hospital. No prophylactic therapy was administered. The patient was considered to have Kounis syndrome, and she was placed on a therapy involving acetylsalicylic acid 300 mg, epinephrine 1 mg iv, and infusion of isotonic solution (NaCl 0.9%) with which arterial blood pressure gradually increased. In the physical examination 15 min later, blood pressure was 118/85 mm Hg, chest pain subsided, and ST-segment elevations reciprocal changes in anterior leads on ECG disappeared. The laboratory tests conducted upon admission revealed mild leukocytosis (leukocyte count = 12.380/μl) and eosinophilia (1.2%). Immunoglobulin E level was elevated (180 g/l). During the four days of hospitalization in the coronary intensive care unit, troponin I levels remained stable and chest pain did not re-occur. The patient was clinically and hemodynamically stable during the hospitalization period, and she was then discharged from the hospital and she was prescribed diltiazem 60 mg once daily, isosorbide mononitrate 20 mg once daily, and desloratadine 5 mg once daily to be taken perorally.