Authors’ Reply: Adrenaline, Aspirin, and Corticosteroids Should Be Administered Mindfully While Treating Myocardial Infarction and Kounis Syndrome

We appreciate the authors’ insightful comments regarding the therapeutic complexity in treating Kounis syndrome.[1] Therapeutic management of Kounis syndrome is challenging because it needs to treat both cardiac and allergic symptoms simultaneously. Drugs administered to treat the cardiac manifestations can worsen allergy, and drugs given to treat the allergic symptoms can aggravate the cardiac function.[2] We wholly agree with the concerns on the use of intramuscular adrenaline and that was exactly why we avoided it in our patient We agree that certain controversies exist regarding the use of aspirin in type 1 Kounis syndrome, whereas it is a mainstay of acute coronary syndrome therapy and recommended in type 2 and type 3 Kounis syndrome. However, Kounis syndrome is a complex clinical entity characterized by the coexistence of acute coronary syndrome and mast cell-mediated allergic inflammation.[2,3] In the absence of guidelines, clinical consensus suggests overall benefit, with its advantages outweighing the potential risks, particularly as it has demonstrated efficacy in reducing prostaglandin D2 levels.[4] Aspirin was administered in the present case due to objective biochemical evidence of myocardial injury and the inability to definitively exclude type 2 Kounis syndrome. Although aspirin can exacerbate allergic pathways via cyclooxygenase-1 inhibition and leukotriene overproduction, its use was carefully individualized after confirming the absence of prior aspirin hypersensitivity and under close clinical and electrocardiographic monitoring Hydrocortisone was administered as adjunctive therapy to suppress mast cell-mediated inflammation and platelet activation, reduce cytokine-driven coronary vasospasm, and prevent late-phase or biphasic allergic reactions. Corticosteroids have been used in type 1 Kounis syndrome when allergic manifestations are prominent.[2] While hypersensitivity reactions to corticosteroids – particularly succinate esters – have been reported, these events remain uncommon.[5] No adverse reaction attributable to hydrocortisone was observed in this patient. We acknowledge that therapeutic decisions in Kounis syndrome must be individualized, and our choices reflected the clinical context of this case. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.