Iranian Heart Journal

Iranian Heart Journal

Kounis Syndrome: Acute Myocardial Infarction Following Multiple Bee Stings

Document Type : Case Report

Authors
Barun Kumar
Kishan Mavani
Kanika Kukreja
Department of Cardiology, All India Institute of Medical Sciences, Rishikesh, India.
Abstract
Introduction: Kounis syndrome is an acute coronary syndrome triggered by allergic or hypersensitivity reactions. It is an underdiagnosed clinical entity where mast cell activation leads to coronary vasospasm, plaque erosion, or thrombosis. Hymenoptera stings, such as those from bees, are a rare but well-documented cause.
 
Case Presentation: A 64-year-old man presented to the emergency department with multiple bee stings, manifesting only mild cutaneous urticaria. He was discharged after observation with stable vitals. Approximately 12 hours post-sting, he experienced sudden-onset chest pain, diaphoresis, and syncope. Upon arrival, he was in a gasping state, requiring immediate intubation and mechanical ventilation. He suffered a cardiac arrest, and after 30 minutes of cardiopulmonary resuscitation, return of spontaneous circulation was achieved. Electrocardiography revealed ST-segment elevation in the inferior leads (II, III, and aVF) with reciprocal ST-depression in the anterolateral leads. Emergency coronary angiography demonstrated a complete thrombotic occlusion of the mid-right coronary artery. Successful primary percutaneous coronary intervention with a drug-eluting stent was performed, restoring TIMI grade 3 flow.
 
Conclusions: This case highlights the critical importance of considering Kounis syndrome in patients presenting with acute coronary symptoms following an allergic insult, even with a delayed presentation. A high index of suspicion is necessary for timely diagnosis and management, which must address both the allergic reaction and the acute coronary syndrome concurrently. (Iranian Heart Journal 2026; 27(2): 81-86)
Keywords
Kounis syndrome
bee sting
acute myocardial infarction
allergic angina
primary percutaneous coronary intervention
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Iranian Heart Journal
Volume 27, Issue 2
Spring 2026
Pages 81-86