RevBrasAnestesiol.2016;66(2):194---196
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
MISCELLANEOUS
Cardiac
complications
in
a
metamizole-induced
type
I
Kounis
syndrome
Jose
F.
Martínez
Juste
∗,
Tomas
Ruiz
Garces,
Rafael
Gonzalez
Enguita,
Pedro
Cia
Blasco,
Jara
Altemir
Trallero
AnesthesiologyDepartment,HospitalClínicoUniversitarioLozanoBlesa,Zaragoza,Spain
Received28May2013;accepted9July2013 Availableonline4November2013
KEYWORDS
Kounissyndrome; Metamizole; Cardiogenicshock; Asystole
Abstract Kounissyndromeisdefinedasthecoincidentaloccurrenceofallergicreactionand acutecoronarysyndromesecondarytovasospasm.Anti-inflammatorydrugsareincludedasone ofthemultiplecauses.Currentdataavailableaboutthissyndromecomefromcasereports. Wepresentthecaseofapatient whosufferedKounissyndromewithcardiogenicshockand asystoleafterintravenousinfusionofMetamizole,andinwhichnolesionswereobservedin coronariography.
©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
SíndromedeKounis; Metamizol;
Choquecardiogênico; Assistolia
Complicac¸õescardíacasemsíndromedeKounistipoIinduzidapormetamizol
Resumo AsíndromedeKounisédefinidacomoaocorrênciaconcomitantedereac¸ãoalérgica esíndromecoronarianaagudasecundáriaaovasoespasmo.Osmedicamentosanti-inflamatórios estãoincluídoscomoumadasmúltiplascausas.Osdadosatuaisdisponíveissobreessasíndrome sãoprovenientesderelatosdecasos.Apresentamosocasodeumpacientequeapresentou sín-dromedeKouniscomchoquecardiogênicoeassistoliaapósinfusãointravenosademetamizol, enoqualnãoforamobservadaslesõesnacoronariografia.
©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
The association between coronary event and acute aller-gic reaction was first described in 1950 in a case report
∗Correspondingauthor.
E-mail:[email protected](J.F.M.Juste).
of a patient withan allergic reaction topenicillin.1
Sub-sequently, in 1996, Kounis syndrome was defined as the
coincidentalappearanceofallergicreactionandacute
coro-narysyndromesecondarytovasospasm.2,3Twovariantshave
been described: type I, occurring in patients with
nor-mal coronary arteries, and type II, occurring in patients
with coronary artery atheromatous disease shown
angio-graphically, in which the allergic reaction can erode and
Cardiogenicshockandasystolesecondarytometamizole-inducedtypeIKounissyndrome 195
provoke atheromatous plaque rupture in addition to the
vasospasm.4,5 Several conditions have been reported as
capableofinducingKounissyndrome;drugs,food,mosquito
bite,environmentalexposures.4Themechanismwhythese
allergensproducecoronaryvasospasmisthroughmastcell
degranulation and ultimately the release of vasoactive
mediators (histamine, leukotrienes, serotonin) and
pro-teases(tryptase,kinase).3
In this report,the patient sufferedcoronary syndrome
duetovasospasmwithcardiogenicshockandasystoleafter
intravenousmetamizoleinfusion.
Case
report
We describe a case of a 66-year-old man with unknown
drugallergiesandamedicalbackgroundofdyslipemiaand
chronic bronchitis. Radical prostatectomy, several
endo-scopic polypectomies, and adenocarcinoma rectosigmoid
anteriorresectionformed hissurgical background.Hewas
operatedonliverbipartitionwithrightportalligation and
excisionoftwolivermetastasesinsegmentsIIandIV,under
generalanesthesia.
Towardtheendofthesurgery,duringtheabdominalwall
closureandcoincidingwith2g.ofmetamizoleintravenous
administration, the patient presented ST segment
eleva-tioninmonitoredleads(IIandV5),severehypotensionand
bradycardia,alongwiththeappearanceofatrunkandneck
skinrash.Itwastreatedwith100mgofephedrine,2mgof
atropine,4mgofadrenaline,5mgofdexchlorpheniramine,
100mgofhydrocortisone,andfluidreplacement.
Atthatmoment,anECGwasmadeandshowedcomplete
atrioventricularblockandSTelevationinleads II,III,aVF,
V5andV6.Thepatientwasmovedtothehemodynamicunit
as soon as the abdominal wall closure was finished.
Dur-ingthepatienttransfer,hemodynamicinstabilitygotworse
andasystoleoccurred,socardiopulmonaryresuscitationwas
initiated andmore adrenalineadministered.Within afew
minutes,changefromasystoletoventricularfibrillationwas
noticedonthemonitorscreenandtwoelectricshockswere
administeredafterwhichsinusrhythmwasrecovered.
Car-diac catheterization was performed and right dominance
and an absence of coronarylesions were revealed in the
coronariography.
The patientwaslatertransferredtotheintensivecare
unitwhereanelevationofcardiacenzymes(peaktroponin
I of 1.26mg/mL) and serum tryptase levels were showed
withsubsequentdeclineofbothvalues.Anechocardiogram
was performed in which completely normal contractility
wasshowed.Duringhisstay inthe ICU,vasopressordrugs
treatmentwasgraduallydecreasedandfinallywithdrawn.
STelevationreturnedtobaselineandcardiacenzymesand
tryptaserestoredtonormalvaluesinthefirst24h.
Extuba-tionwasperformed on thethird day andthe patientwas
discharged from the unit and transferred to the General
Surgerywardduetohissatisfactoryprogress.
Discussion
The relation betweenanaphylaxisand coronarysymptoms
has been well documented on numerous occasions since
publication of the firstcase in 1950. Despite this, Kounis
syndromecontinuesbeinganunderdiagnosedentity3,6that
shouldbe considered in the differential diagnosis of
car-diogenic shock.6 Also, it would be useful to optimize its
diagnosistoruleouttheallergicreactionasapossiblecause
in all patients whocome tothe emergency services with
chestpainandSTelevationintheelectrocardiogram.7
Current data concerning etiology,clinic, diagnosis and
therapeuticpossibilities,comefromnearly300cases
pub-lished in the literature.5 In terms of etiology, the agents
thatcouldcauseaKounissyndromearenumerous.Within
drugs, beta-lactams,NSAIDs, andiodinated contrast have
beendescribedasthemostfrequentlyagentsinvolvedinits
appearance.3,6Inthisreport,eventhoughthepatienthad
alreadyreceivedother differentanalgesicsduringsurgical
operation,thecoincidenceofsuggestivesignsof coronary
vasospasmand anaphylactic reaction occurred during the
intravenousadministrationofmetamizole,sothisdrugwas
consideredtheallergen thatcaused theclinical
presenta-tion.
Mast cell degranulation with vasoactive mediators
releaseisthepathophysiologicmechanismofthissyndrome,
which is mainly diagnosed by clinical manifestations,and
in which cardiac manifestations and electrocardiographic
findingsareveryvaried. Unstableangina,withor without
dataofvasospasmandacutemyocardialinfarctionarethe
most common forms described for coronary event within
Kounissyndrome.3,8The presentationascardiogenic shock
isextremely infrequent,6 and onlytworeports have been
previouslypublished.6,9
Therearenospecificclinicalpracticeguidelinesforthe
Kounissyndrome treatment.3,6 The current recommended
treatmentisthecombinedtherapyofacutecoronary
syn-dromeandanaphylaxis,3takingintoaccountthatsomedrugs
usedtotreatcoronarysyndromemayaggravate
anaphylac-ticreactionandviceversa.
In summary, we present a case in which intravenous
metamizole acted as allergen, triggering an acute
aller-gic reaction accompanied by coronary syndrome,with an
absenceof lesionsin coronaryarteries.This is defined as
KounissyndrometypeI.Theparticularfeatureofthisreport
isthatthepatientpresentedcardiogenicshockandasystole
ascardiacmanifestations,bothbeinghighlyunusualinthese
situations.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
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infarction.Circulation.1996;94:1789.
3.RicoCepedaP,PalenciaHerrejónE,RodríguezAguirregabiriaMM. SíndromedeKounis.MedIntensiva.2012;36:358---64.
196 J.F.M.Justeetal.
6.GarcipérezdeVargasFJ,MendozaJ,Sánchez-CalderónP,etal. Shock cardiogénico secundario a síndrome de Kounis tipo II inducidopormetamizol.RevEspCardiol.2012;65:646. 7.Biteker M. Kounis syndrome: a forgotten cause of chest
pain/cardiac chest pain in children. Anadolu Kardiyol Derg. 2010;10:382.
8.Gómez Canosa MS, Castro Orjales MJ, Rodríguez Fari˜nas FJ, et al. Tratamiento del síndrome de Kounis. Med Intensiva. 2011;35:519---20.
