2022 FSA Podium and Poster Abstracts

S002: KOUNIS SYNDROME, AN UNRECOGNIZED PRESENTATION OF ANAPHYLAXIS
Zachary Fleissner, DO; Andrew Hong, MD; Cesar Campos-Cuellar, MD; Alexei Gonzalez-Estrada, MD; R. Doris Wang, MD; Sher-Lu Pai, MD; Mayo Clinic, Jacksonville, Florida

Introduction: The incidence of near-fatal and fatal perioperative anaphylaxis in the US is 1.26 per 100,000 procedures. Kounis syndrome (KS) is an acute coronary syndrome resulting from the activation of an immune cascade.

Case Report 1: A 52-year-old male with history of end-stage renal disease, type 1 diabetes mellitus, and diastolic heart dysfunction presented for renal transplantation. Known allergies included cephalosporins and quinine. Induction of anesthesia was performed with lidocaine, propofol, and rocuronium. Chlorhexidine was used before placement of a central venous catheter and radial arterial line. A latex foley was placed. Upon completion of the line placements, the patient became diaphoretic with mean arterial pressures (MAP) in the 30-40s mmHg and electrocardiogram (ECG) ST elevations. Echocardiography showed diminished biventricular cardiac contractility with dilated chambers. A high dose epinephrine infusion improved the blood pressure, resolving ST segment changes, and improving contractility. Transplant was canceled and hydrocortisone was started in the intensive care unit (ICU). In 6 hours, epinephrine was weaned off with the patient being stable and extubated. No significant changes in troponin levels were found. Postoperative echocardiography showed no significant abnormalities. The patient’s aST levels at the time of the event returned at 223 ng/mL (normal <11.5 ng/ml). Histamine levels were 10 ng/mL (normal 0-1 ng/mL). He underwent extensive allergy testing for all the medications and disinfecting solutions used during the case which all returned negative. A serum specific latex IgE was 12.5 kU/L (ref; <0.05) which is suggestive of a latex allergy.

Case Report 2: A 64-year-old male with history of coronary artery disease status post stenting, hypertension, obstructive sleep apnea, and cervical radiculopathy presented for C5-C7 anterior cervical discectomy. Induction of anesthesia was performed with lidocaine, propofol, and succinylcholine. Maintenance anesthesia included intravenous infusion of remifentanil, propofol, and dexmedetomidine. A radial arterial line and latex foley were placed. Cefazolin was administered as the perioperative antibiotic. During initial neck dissection, the patient’s blood pressure decreased from 115/60 mmHg to 60/35 mmHg and heart rate increased from 75 bpm to 120 bpm with ECG ST segment elevation. Surgery was aborted as ST-elevation myocardial infarction (STEMI) code was activated. Intraoperative transesophageal echocardiogram showed hyperdynamic myocardium but was otherwise unremarkable.  A rash was noted over the patient’s shoulders.  An allergic reaction with coronary spasm was suspected, prompting intravenous diphenhydramine, famotidine, and methylprednisolone, which later resolved the hypotension and ST elevation. There was no bronchospasm or airway swelling, so the patient was extubated in the operating room. However, the latex foley was left in place. Follow up echocardiography showed no significant abnormalities. The patient was later found to have serum acute tryptase of 28.3 ng/ml (normal <11.5 ng/ml) and latex IgE of 3.43 kU/l (positive), also suggestive of an unknown latex allergy.

Conclusion: Anaphylaxis can present in the form of ST-segment elevations caused by coronary vasospasm from histamine and inflammatory mediators that is known as KS. Management includes early recognition for anaphylaxis, hydrocortisone, antihistamines, and discontinuing any possible offending agents. Obtaining a tryptase level is important in the diagnosis of anaphylaxis.