Anaphylactic shock and ST-elevation Myocardial infarction Following a Bee Sting: two deadly diseases in a patient with Kounis Syndrome

Guido Del Monaco^1,2Carolina Pascucci^1,2Federica Catapano^2,3Giulio G Stefanini^1,2Giuseppe Ferrante^1,2*

• ¹Department of Cardiovascular Medicine, Humanitas Research Hospital, Milan, Lombardy, Italy
• ²Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
• ³Department of Radiology, Humanitas Research Hospital, Rozzano, Italy

Kounis syndrome is an acute coronary syndrome occurring in the setting of an allergic reaction, usually caused by drug administration, food ingestion, or insect sting.We report the case of an elderly woman who presented to the emergency room suffering from an anaphylactic shock caused by a bee sting and who was diagnosed an antero-lateral STEMI with moderately impaired left ventricular ejection. The patient was successfully managed with administration of intravenous antihistaminic drugs and steroids, intravenous fluid volume resuscitation and intramuscular epinephrine. Then, the patient underwent emergency coronary angiography which showed a thrombotic subtotal occlusion of the proximal LAD and occlusion of the very distal apical LAD due to spontaneous embolism, that was treated by primary PCI with thrombus aspiration and DES implantation to the proximal LAD achieving a good angiographic result. Nevertheless, on day 3 the patient developed a left ventricular apical thrombosis, as assessed by cardiac magnetic resonance, requiring oral anticoagulation with rivaroxaban, de-escalation of dual antiplatelet therapy from ticagrelor to clopidogrel on top of acetylsalicylic acid and finally a switch to dual antithrombotic therapy. Three months follow-up was uneventful. This case highlights the importance of prompt identification of Kounis syndrome in patients presenting with severe allergic reactions to allow a timely implementation of appropriate reperfusion strategies in such high-risk patients with STEMI.