BACKGROUND
Kounis syndrome (KS) is an infrequently diagnosed entity that has been established as a hypersensitivity coronary disorder induced by various conditions such as drugs, environmental exposures, foods and coronary stents (1). Its presence is a life-threatening pathology that may make the anesthetic management difficult. 

CASE REPORT
A 49-year-old man with no cardiovascular risk factors was sheduled for left perthrocanteric hip fracture osteosynthesis. Once in the PACU and five minutes after metamizol administration, he experienced nauseas, itching in the mouth, burning face, sudden shortness of breath and decreased level of consciousness. In the monitor of the PACU, we could see an ST-segment elevation followed by a high degree AV block. He requires CPR, intubation and administration of corticoids. On admission at ICU, the first ECG revealed ventricular tachycardia, ST elevation in leads II, III, aVF and non-ST-segment elevation in aVL and V2-V4 (fig.1). Echocardiogram, CT angiogram and Troponin T were normals. After 2 hours, the ECG revealed an atrial fibrillation which requires electrical and medical cardioversion (fig.2). The patient became hemodynamically stable and the ECG became normal (fig.3). Coronary angiogram revealed normal epicardial coronaries and blood tests revealed levels of IgE, tryptase and urine metilhistamine elevated. After 12 hours of admission, the patient could be extubated and discharged from the ICU.

DISCUSSION
In our case, patient describes to take metamizol several times before without any adverse event, and that’s why we didn’t suspect at all.
Management could be difficult because some drugs used in acute coronary syndrome (ACS) such as acetylsalicylic acid or nitroglycerin can exacerbate anaphylaxis. Even in non expected cases, KS should be suspected and it’s important to adequately balance the risks and benefits individually to establish the most appropriate treatment.

LEARNINGS POINTS
KS is not a rare disease but an infrequently diagnosed condition. We should keep in mind when diagnosing patients with no cardiovascular risk factors who experience ACS accompanied by symptoms of anaphylaxis. 

Faced with a patient with KS, we recommend:
1.Treat simultaneously anaphylaxis and ACS
2.Diagnose the type of KS 
3.Avoid possible triggers (drugs, …)
4.The anesthesiologist must know the algorithm for action in anaphylaxis and in ACS. 


08 / Kounis syndrome: myth or reality?
Álvarez M, Salas E, Galiana M, Ferrero C, Elias M, Gómez L.
Department of Anaesthesiology and Critical Surgical care. Hospital General Universitario Alicante. Spain

08 / Kounis syndrome: myth or reality? Álvarez M, Salas E, Galiana M, Ferrero C, Elias M, Gómez L. Department of Anaesthesiology and Critical Surgical care. Hospital General Universitario Alicante. Spain