Kounis syndrome resulting from anaphylaxis to diclofenac
A 64-year-old man was admitted for surgical correction following fracture of both bones of the left leg. During pre-anaesthetic check-up, his blood pressure was recorded as 134/86 mmHg and pulse rate was 70/min. The patient was not a known smoker or alcoholic. There was no history of allergy, bronchial asthma or any previous surgeries. His functional capacity was 7 metabolic equivalents. His airway was graded as Mallampatti class 2. Systemic examination was normal. All investigations, including kidney function, haemogram, urine, random blood sugar, electrocardiogram and chest X-ray, were within normal limits. He was accepted for anaesthesia under ASA physical status class I.\nIn the ward, the patient complained of severe pain and was given diclofenac sodium 50 mg intramuscular in the gluteal region. Ten minutes thereafter, the patient developed chest pain and pruritus over the lip along with redness and wheal over the site of injection. His blood pressure was found to be 70/54 mm of Hg with a heart rate of 104 beats per minute. Electrocardiography (ECG) showed ST-segment elevation in leads II, III and avF. An ST-segment elevation myocardial infarction (STEMI) of inferior wall was diagnosed and, following primary management, the patient was immediately shifted to the intensive care unit and cardiology consultation was sought. Detailed physical examination of the patient revealed diffuse erythema and rash primarily over the trunk, allergic etiology of the cardiac event was considered in view of the clinical history and temporal relationship with intramuscular diclofenac sodium injection.\nTreatment was started with 0.1 mg adrenaline (1 in 10,000) and 10 mg chlorpheniramine maleate IV, along with 125 mg of methyl prednisolone. Intravenous administration of fluid was continued. Emergent coronary angiography revealed normal coronary vessels. The troponin T level was found to be elevated, but levels of creatine kinase (56 units/L) and creatine kinase-MB (3 units/L) fractions remained normal.\nThe patient's blood pressure by this time was 104/68 mmHg. The rashes disappeared completely over the next 2–3 h and the electrocardiographic findings returned to normal. Serum tryptase however was found to be elevated, which was done before shifting the patient to the cath lab and also 2 h after the coronary event. The patient was discharged to home after conservative management for the fracture and asked to come for surgery at a later date.