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Kounis Syndrome Associated With Selective Anaphylaxis to Cefazolin.

Kounis syndrome (KS) was first described in 1991 by Kounis and Zavras [1]. The syndrome is characterized by the simultaneous presence of anaphylactic and cardiac events [1]. KS is also known as allergic angina or allergic myocardial infarction. It is thought that following an allergic stimulus, inflammatory mediators are released by mast cells, leading to spastic contraction of coronary smooth muscle cells [2,3]. Three types of KS have been described [4], as follows: type I, coronary vasospasm without significant coronary disease; type II, patients with pre-existing coronary disease in which the release of pro-inflammatory mediators (histamine, leukotrienes and serotonin) can cause vasospasm or instability of atherosclerotic plaques; and type III, in which drugeluting stent thrombosis is associated with a hypersensitivity reaction [5]. Although several drugs (antibiotics, nonsteroidal anti-inflammatory drugs, anticoagulants, corticosteroids, anesthetics, and contrast media) have been associated with KS, antibiotics are the most frequently involved [6,7]. Recently, Renda et al [8] identified the largest case series on KS associated with antibiotics, with 37.5% of all cases involving amoxicillin/clavulanic acid (6 cases) and the remaining 10 cases caused by amoxicillin alone, piperacillin/tazobactam, ceftriaxone, cefazolin, levofloxacin, and metronidazole. We report the case of a 56-year-old man who developed KS immediately after intravenous administration of cefazolin. To the best of our knowledge, this is the first case of KS with selective anaphylaxis to cefazolin. Sánchez et al [9] reported type I KS due to rocuronium and/or cefazolin with positive skin test results to both drugs, although, given that the authors did not present any further data (skin test with the remaining ß-lactams or drug provocation tests), we cannot consider this case to be clearly selective or even caused only by cefazolin. The patient had a medical history of dyslipidemia and no personal history of allergy, although he did have a family history of drug allergy (brother with a history of penicillin allergy). He underwent knee arthroscopy (for meniscus tear), with no complications during the procedure. He was always kept under Manuscript received September 7, 2017; accepted for publication February 27, 2018.