Background: Kounis syndrome (KS), an acute coronary event triggered by anaphylaxis, is observed in 2%-3.4% of allergic reactions, affecting patients with preexisting arterial disease as well as healthy individuals. KS is associated with the release of inflammatory mediators such as histamine, neutral proteases, platelet activating factor, cytokines and chemokines, causing coronary vasospasm. Case report: A 57-year old woman with diabetes (treated with metformin/vildagliptin) and arterial hypertension (treated with amlodipine), but no history of allergy, was a candidate for colecystectomy. Normal test results for ECG, ergometrics, chest x-ray were provided by the patient. She was monitored for cardioscopy, SpO2, NIBP and BIS. General anesthesia was induced with sufentanil (50 g), propofol (180 mg) and cisatracurium (6 mg), followed by tracheal intubation and capnography. After antibiotic administration (2g cefazolin), the patient displayed progressive hypotension (50 x 22 mmHg), flattening of the capnography curve, and tachycardia (125 bpm). Ephedrine (total: 50 mg) was administered, with no result. Intense skin pallor set in, and after some minutes diffuse changes in ventricular repolarization were observed on cardioscopy, suggesting an acute coronary event. Hypotension was corrected with infusion of noradrenaline, and intense flushing and edema of the face and extremities occurred. Intubated, the patient was admitted to the ICU. The ECG changes persisted for approximately 1 hour, but the troponin and CK-MB levels and coronary angiography findings were normal. After 18 hours of satisfactory improvement, the patient was extubated. Discussion: ECG changes may be justified by myocardial ischemia from systemic hypotension, but in our patient the changes persisted despite successful treatment of hypotension. Epinephrine is the drug of choice in anaphylaxis, but in KS this drug can worsen coronary vasospasm. The early identification of KS and the choice of a treatment capable of controlling anaphylactic manifestations without aggravating coronary vasospasm are crucial to ensure favorable outcomes.  


07 / Kounis Syndrome during general anesthesia for colecystectomy: a case report