A bee sting in a 61-year-old man with known venom allergy triggered Kounis syndrome, presenting as concurrent anaphylactic shock and STEMI that ultimately resulted in death despite revascularization.
Case Report (n=1)
This case highlights the diagnostic and therapeutic challenges of Kounis syndrome, emphasizing the need for careful management when anaphylaxis and acute coronary syndrome occur concurrently.
Abstract Kounis syndrome is defined as the concurrence of acute coronary syndrome (ACS) with an acute allergic or hypersensitivity reaction. The proposed mechanism involves allergy-mediated coronary vasospasm and plaque destabilization. Although Kounis syndrome may account for up to 1.1% of all hospitalized allergic reactions, it remains underrecognized and often misdiagnosed. We present a case of ST-elevation myocardial infarction (STEMI) occurring in the setting of anaphylactic shock following a bee sting. A 61-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and coronary artery disease status post percutaneous coronary intervention (drug-eluting stent to the RCA in 2024) and known bee venom allergy presented via EMS after a bee sting with respiratory distress and loss of consciousness. On arrival, he was pulseless and apneic. Advanced cardiac life support was initiated for pulseless electrical activity arrest, with return of spontaneous circulation after seven rounds of CPR. Post-resuscitation ECG revealed ST-segment elevations in the inferior leads with reciprocal changes. A STEMI alert was activated, and emergent coronary angiography demonstrated total occlusion of the distal LAD (unable to recannulate), 80% thrombotic stenosis of the proximal LAD (treated with a drug-eluting stent), 80% stenosis of the proximal circumflex artery, and a patent RCA stent with 30% restenosis. Left ventriculography showed an LVEF of 50-55%. Despite revascularization, the patient developed refractory shock. Bedside POCUS revealed preserved cardiac output, suggesting distributive shock physiology. Echocardiography later showed severely reduced LVEF (10-15%) with anteroseptal and apical hypokinesis. His hospital course was complicated by ventilator-dependent respiratory failure, acute renal failure requiring renal replacement therapy, and anoxic brain injury. After goals-of-care discussions, comfort measures were initiated, and the patient passed peacefully surrounded by family. This case underscores the diagnostic and therapeutic challenges when anaphylaxis and ACS occur concurrently. Kounis syndrome, though traditionally considered rare, is likely underdiagnosed. Its recognition is critical, as management differs from isolated anaphylaxis or ACS—particularly regarding the cautious use of epinephrine and beta-blockers. Increased awareness and reporting of Kounis syndrome can aid in refining management strategies for patients presenting with overlapping allergic and ischemic events, ultimately improving outcomes. This abstract is funded by: None
Vuchula et al. (Fri,) conducted a case report in Kounis syndrome, Anaphylaxis, STEMI (n=1). Percutaneous coronary intervention was evaluated. A bee sting in a 61-year-old man with known venom allergy triggered Kounis syndrome, presenting as concurrent anaphylactic shock and STEMI that ultimately resulted in death despite revascularization.