Acute Myocardial Injury After A Bee Sting: A Case Report of Probable Type 1 Kounis Syndrome

Introduction Kounis syndrome refers to acute coronary syndromes triggered by an allergic reaction, leading to mast cell degranulation and acute myocardial injury. Case Presentation A 51-year-old woman with a history of local reactions to bee venom presented with systemic anaphylaxis (diffuse urticaria, facial flushing, vomiting, abdominal pain) and central chest pain within 10 minutes of a bee sting. Her chest pain began before she received a single intramuscular dose of 0.5 mg epinephrine. Initial and serial electrocardiograms (ECGs) showed a normal sinus rhythm without transient ST-segment or T-wave abnormalities. Echocardiography indicated a preserved ejection fraction of 60%. However, high-sensitivity troponin I (hs-cTnI) levels rose and fell rapidly, peaking at 368.2 ng/L (upper reference limit: 20.7 ng/L), confirming acute myocardial injury. Recognizing the allergic trigger led to an initial diagnosis of probable Type 1 Kounis syndrome. Because she was hemodynamically stable and asymptomatic, non-invasive coronary computed tomography angiography (CTA) was chosen over invasive angiography as a patient-specific decision to evaluate her coronary anatomy. Oral diltiazem was given primarily to optimize heart rate for imaging. Based on an individualized assessment, standard acute coronary syndrome medications, such as beta-blockers and aspirin, were withheld to avoid theoretically worsening the hypersensitivity response or precipitating paradoxical vasospasm. The CTA showed an Agatston calcium score of zero and normal coronary arteries. Conclusions Suspecting probable Kounis syndrome in patients with anaphylaxis and acute myocardial injury facilitates individualized management. Without tryptase measurement, provocation testing or cardiac magnetic resonance imaging, the diagnosis remains probable and myocarditis cannot be excluded. A single case cannot establish the safety of this individualized management. Graphical abstract Summarizing the clinical course and management of probable Type 1 Kounis syndrome after a bee sting. The flowchart shows the patient's presentation, the diagnostic findings, the process of clinical decision-making, the non-invasive evaluation and follow-up. Image Credit & Methodology: The 3D cardiac reconstruction and the coronary CTA lumen images are original clinical images taken from the patient. The illustrations of the bee, the mast cell, the bronchodilator inhaler, and the exclamation mark were drawn by the authors by hand using MS Paint. The basic silhouette icons (patient, checklist, presentation) are standard, royalty-free assets that are included in Microsoft PowerPoint. The authors assembled the final figure directly in Microsoft PowerPoint without using generative AI tools or copyrighted third-party materials.