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Peer-reviewedCC BY-NC-NDJournal of medical case reports

Type I Kounis syndrome after the Nuss procedure-diagnostic challenge for thoracic surgeons: a case report.

  • Che-Chia Chang1
  • Kuan-Hung Yeh2,3
  • Nay Htut4
  • Baptiste Massart4
  • Yeung-Leung Cheng5,6
6 affiliations
  1. 1Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Shengli Rd., North Dist., Tainan City, Taiwan, 70403.
  2. 2Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian Gao Rd, Xindian Dist., New Taipei City, Taiwan, 23142.
  3. 3School of Medicine, Tzu Chi University, Hualien City, Taiwan, No. 701, Sec. 3, Zhongyang Rd., 970374.
  4. 4Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian Gao Rd, Xindian Dist., New Taipei City, Taiwan, 23142.
  5. 5Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian Gao Rd, Xindian Dist., New Taipei City, Taiwan, 23142. [email protected].
  6. 6School of Medicine, Tzu Chi University, Hualien City, Taiwan, No. 701, Sec. 3, Zhongyang Rd., 970374. [email protected].
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Abstract

Background

Kounis syndrome refers to acute coronary syndrome precipitated by an allergic or anaphylactic reaction that has a slight predominance in male patients. The most frequently reported symptom is chest pain. Kounis syndrome is a rare and frequently underdiagnosed condition that demands a high degree of clinical suspicion. To the best of our knowledge, this is the first reported case of type I Kounis syndrome after the Nuss procedure with clinically obscured chest pain.Case presentation

A 32-year-old Taiwanese woman underwent the Nuss procedure and received intravenous Clindamycin and Ketorolac postoperatively. Generalized wheals, pruritus, and shock developed, and she was treated in accordance with the diagnosis of anaphylaxis. Postoperative pain from the Nuss procedure and the use of analgesics masked ischemic chest pain, delaying prompt clinical evaluation. Electrocardiographic findings demonstrated elevation of the ST-segment in the precordial leads V4, V5, and V6 and an elevated high-sensitivity troponin I level. Echocardiography revealed no left ventricular wall motion abnormalities or pericardial effusion. Coronary angiography was omitted because imaging artifacts from the surgical bars introduced during the Nuss procedure limited visual field, compromising its diagnostic value. The high-sensitivity troponin I level improved progressively with conservative treatment. The subsequent hospital course was uneventful, with the patient remaining stable. A diagnosis of Kounis syndrome was established, and the patient was discharged.Conclusions

Kounis syndrome is an underdiagnosed disease with newly proposed etiologies but no treatment guidelines. Clinical awareness is essential when treating anaphylaxis given the possibility of concurrent acute coronary syndrome, especially in patients undergoing the Nuss procedure, as chest pain may be masked. Kounis syndrome should be considered alongside other differential diagnoses.

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Cite

BibTeXRIS
BibTeX
@article{chang2026type,
  title = {{Type I Kounis syndrome after the Nuss procedure-diagnostic challenge for thoracic surgeons: a case report.}},
  author = {Che-Chia Chang and Kuan-Hung Yeh and Nay Htut and Baptiste Massart and Yeung-Leung Cheng},
  journal = {Journal of medical case reports},
  year = {2026},
  month = aug,
  doi = {10.1186/s13256-026-06424-x},
  url = {https://europepmc.org/article/MED/42958429},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Type I Kounis syndrome after the Nuss procedure-diagnostic challenge for thoracic surgeons: a case report.
AU  - Che-Chia Chang
AU  - Kuan-Hung Yeh
AU  - Nay Htut
AU  - Baptiste Massart
AU  - Yeung-Leung Cheng
PY  - 2026
DA  - 2026/08/01
JO  - Journal of medical case reports
DO  - 10.1186/s13256-026-06424-x
UR  - https://europepmc.org/article/MED/42958429
AB  - Background  Kounis syndrome refers to acute coronary syndrome precipitated by an allergic or anaphylactic reaction that has a slight predominance in male patients. The most frequently reported symptom is chest pain. Kounis syndrome is a rare and frequently underdiagnosed condition that demands a high degree of clinical suspicion. To the best of our knowledge, this is the first reported case of type I Kounis syndrome after the Nuss procedure with clinically obscured chest pain.Case presentation  A 32-year-old Taiwanese woman underwent the Nuss procedure and received intravenous Clindamycin and Ketorolac postoperatively. Generalized wheals, pruritus, and shock developed, and she was treated in accordance with the diagnosis of anaphylaxis. Postoperative pain from the Nuss procedure and the use of analgesics masked ischemic chest pain, delaying prompt clinical evaluation. Electrocardiographic findings demonstrated elevation of the ST-segment in the precordial leads V4, V5, and V6 and an elevated high-sensitivity troponin I level. Echocardiography revealed no left ventricular wall motion abnormalities or pericardial effusion. Coronary angiography was omitted because imaging artifacts from the surgical bars introduced during the Nuss procedure limited visual field, compromising its diagnostic value. The high-sensitivity troponin I level improved progressively with conservative treatment. The subsequent hospital course was uneventful, with the patient remaining stable. A diagnosis of Kounis syndrome was established, and the patient was discharged.Conclusions  Kounis syndrome is an underdiagnosed disease with newly proposed etiologies but no treatment guidelines. Clinical awareness is essential when treating anaphylaxis given the possibility of concurrent acute coronary syndrome, especially in patients undergoing the Nuss procedure, as chest pain may be masked. Kounis syndrome should be considered alongside other differential diagnoses.
SN  - 1752-1947
ER  -