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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Kounis syndrome was described in 1991 by Kounis and Zavras as the simultaneous onset of acute coronary events and allergic anaphylactic or anaphylactoid reactions&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> There are 3<span class="elsevierStyleHsp" style=""></span>subtypes of this condition<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>&#58; type 1 Kounis syndrome in patients with no coronary artery disease&#44; type 2 Kounis syndrome in patients with coronary artery disease and type 3 Kounis syndrome in patients with drug-eluting stent thrombosis&#46; The diagnosis is eminently clinical<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> and is based on objective signs and symptoms suggestive of an anaphylactic reaction and an acute coronary event occurring simultaneously&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a> Treatment is the specific one for acute coronary syndrome and anaphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Our objective was to report the main characteristics of 10<span class="elsevierStyleHsp" style=""></span>patients diagnosed with Kounis syndrome in the past 8<span class="elsevierStyleHsp" style=""></span>years in our department&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">All of the patients were men&#44; with a mean age of 57<span class="elsevierStyleHsp" style=""></span>years&#46; Ninety percent of the patients had no history of allergies or heart conditions&#44; and their most common triggers were food and drugs&#46; The latency varied from immediate to 1<span class="elsevierStyleHsp" style=""></span>h&#46; All patients presented symptoms of anaphylaxis or anaphylactic shock&#44; regardless of the causal agent&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Tryptase in the acute phase was a determinant in 6<span class="elsevierStyleHsp" style=""></span>patients&#44; with high tryptase levels in 5<span class="elsevierStyleHsp" style=""></span>patients &#40;from 18&#46;5 to 84&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L&#41;&#46; In all cases&#44; we observed electrocardiographic abnormalities in the ST segment and increased troponin levels&#46; Coronary angiography was performed on 7<span class="elsevierStyleHsp" style=""></span>patients&#44; 5 of whom had no significant angiographic lesions&#46; One patient presented a lesion in the mid left anterior descending artery&#44; and another presented thrombosis and restenosis of a previous stent&#46; Two of the patients who did not undergo a coronary angiography had an echocardiogram that ruled out ischemic disease&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In terms of treatment&#44; 70&#37; of the patients were treated with intravenous antihistamines and corticosteroids&#44; and only 1 patient was treated with adrenaline&#46; Other treatments included fluid therapy&#44; oxygen therapy&#44; atropine and antiarrhythmic agents&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The prick tests were positive in 4<span class="elsevierStyleHsp" style=""></span>cases &#40;nuts&#44; amoxicillin and metamizole&#41;&#44; and the specific IgE tests were positive in 3<span class="elsevierStyleHsp" style=""></span>cases &#40;nuts and amoxicillin&#41;&#44; taking into account that we did not have commercial extracts for all the suspected allergens&#46; By measuring baseline tryptase levels &#40;with levels &#60;11&#46;4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L considered normal<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&#41;&#44; we showed that the levels returned to normal after each acute episode in all cases&#46; The recommended treatment for all patients was to avoid the allergen trigger&#44; after which the patients remained asymptomatic&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main characteristics of the reactions and the results of the tests&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">There were no differences in our patients in the clinical presentation with the various triggers&#46; The tryptase measurement in the acute phase was of considerable usefulness for the subsequent diagnosis&#46; In terms of treatment&#44; it is worth noting that only one patient was treated with intramuscular adrenaline&#46; This is a highly debated topic<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> because adrenaline is the treatment of choice for anaphylaxis<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;7&#44;9&#44;10</span></a> but has adverse effects that can worsen a ventricular function already compromised by ischemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; adrenaline should be considered as a treatment in the most severe cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We believe it is important for all specialties to understand this disease&#44; because of the essential nature of the initial suspicion of Kounis syndrome when faced with patients with symptoms of anaphylaxis and acute coronary syndrome&#46; An immediate diagnosis is crucial for quickly starting appropriate treatment&#46;</p></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; CAG&#44; coronary angiography&#59; ECG&#44; electrocardiogram&#59; LTP&#44; lipid-transfer protein&#59; LAD&#44; left anterior descending&#59; NP&#44; not performed&#59; PT&#44; prick tests&#59; Tn I&#44; troponin I&#59; Tn T ultraS&#44; ultrasensitive troponin T&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST elevation&#44; negative T wave<br>- Tn I&#58; 1&#46;2<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; lesion in LAD mid and diagonal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metamizole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Generalized erythema&#44; hypotension&#44; pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; negative<br>- Specific IgE&#58; NP<br>- Total IgE&#58; NP<br>- Tryptase&#58; NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST elevation<br>- Tn I&#58; 0&#46;46<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; no significant angiographic lesions on the coronary arteries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moxifloxacin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urticaria&#44; facial angioedema&#44; dyspnea&#44; hypotension&#44; chest pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; NP<br>- Specific IgE&#58; NP<br>- Total IgE&#58; NP<br>- Tryptase&#58; NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST elevation&#44; ventricular tachycardia<br>- Tn I&#58; NP<br>- CAG&#58; late thrombosis and significant restenosis in the stent overlap area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Almonds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dizziness&#44; epigastric pain&#44; generalized erythema&#44; bronchospasms&#44; hypotension&#44; syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; nuts&#44; LTP and flour<br>- Specific IgE&#58; almond 2&#46;98<span class="elsevierStyleHsp" style=""></span>kU&#47;L<br>- Total IgE&#58; 228<span class="elsevierStyleHsp" style=""></span>IU&#47;mL<br>- Tryptase&#58; 10&#160;&#956;g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST reduction<br>- Tn I&#58; 0&#46;12<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; no significant angiographic lesions on the coronary arteries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urticaria&#44; dizziness&#44; general discomfort&#44; headaches&#44; chest pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; negative<br>- Specific IgE&#58; penicillin G&#44; penicillin V&#44; ampicillin&#44; amoxicillin&#44; latex &#60;0&#46;1<span class="elsevierStyleHsp" style=""></span>kU&#47;L<br>- Total IgE&#58; 129<span class="elsevierStyleHsp" style=""></span>IU&#47;mL<br>- Tryptase&#58; NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST reduction<br>- Tn I&#58; 0&#46;87<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin-clavulanate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urticaria&#44; general discomfort&#44; abdominal pain&#44; hypotension&#44; chest pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; negative<br>- Specific IgE &#40;kU&#47;L&#41;&#58; penicillin G 1&#46;85&#59; penicillin V 1&#46;83&#59; ampicillin 0&#46;81&#59; amoxicillin 1&#46;06<br>- Total IgE&#58; 511<span class="elsevierStyleHsp" style=""></span>IU&#47;mL<br>- Tryptase&#58; 84&#46;5&#160;&#956;g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST elevation<br>- Tn I&#58; 0&#46;33<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rabeprazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urticaria&#44; angioedema&#44; general discomfort&#44; hypotension&#44; chest tightness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; negative<br>- Specific IgE&#58; NP<br>- Total IgE&#58; 374<span class="elsevierStyleHsp" style=""></span>IU&#47;mL<br>- Tryptase&#58; 18&#46;5&#160;&#956;g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST reduction<br>- Tn I&#58; 1&#46;77<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; no significant angiographic lesions on the coronary arteries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin-clavulanate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">General discomfort&#44; generalized pruritus&#44; nausea&#44; hypotension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; amoxicillin<br>- Specific IgE&#58; penicillin G&#44; penicillin V&#44; ampicillin&#44; amoxicillin &#60;0&#46;1<span class="elsevierStyleHsp" style=""></span>kU&#47;L<br>- Total IgE&#58; 54&#46;3<span class="elsevierStyleHsp" style=""></span>IU&#47;mL<br>- Tryptase&#58; 38&#46;5&#160;&#956;g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST reduction<br>- Tn I&#58; 0&#46;1<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<br>- CAG&#58; no significant angiographic lesions on the coronary arteries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Almonds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Generalized erythema&#44; abdominal pain&#44; diarrhea&#44; dyspnea&#44; aphonia&#44; hypotension&#44; syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; hazelnut and LTP<br>- Specific IgE &#40;kU&#47;L&#41;&#58; peanut 1&#46;33&#59; hazelnut 0&#46;93&#59; almond 0&#46;64&#59; LTP 2&#46;89<br>- Total IgE&#58; 145<span class="elsevierStyleHsp" style=""></span>IU&#47;mL<br>- Tryptase&#58; 43&#46;9<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST reduction<br>- TnT ultraS&#58; 74<span class="elsevierStyleHsp" style=""></span>ng&#47;L<br>- CAG&#58; no significant angiographic lesions on the coronary arteries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metamizole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immediate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palmar pruritus&#44; general discomfort&#44; bradycardia&#44; hypotension&#44; syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- PT&#58; metamizole<br>- Specific IgE&#58; NP<br>- Total IgE&#58; NP<br>- Tryptase&#58; 25&#46;3<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ECG&#58; ST elevation<br>- Tn T ultraS&#58; 21&#46;22<span class="elsevierStyleHsp" style=""></span>ng&#47;L<br>- CAG&#58; NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "imagenFichero" => array:1 [
                0 => "xTab1818491.png"
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Only the allergens that were positive in the tests were included&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient age&#44; allergen trigger&#44; main characteristics of the reaction&#44; results of the allergological<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> and cardiac studies&#46;</p>"
        ]
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    ]
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Correspondence
Acute coronary syndrome and anaphylaxis
Síndrome coronario agudo y anafilaxia
A. Agulló-Garcíaa,b,
Corresponding author
aagullog@gmail.com

Corresponding author.
, J.L. Cubero Saldañaa,b, S. Ulloa-Levita,b, C. Colás Sanza,b
a Servicio de Alergología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain

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