Type 1 Kounis Syndrome Presenting as Coronary Pseudostenosis During Status Asthmaticus

Background Kounis syndrome is an allergic acute coronary syndrome that may produce multivessel coronary vasospasm, angiographically mimicking obstructive coronary artery disease without atherosclerosis.Case summary A 46-year-old atopic man admitted for status asthmaticus developed inferior ST-segment elevation myocardial infarction, complete heart block, ventricular fibrillation, and cardiogenic shock on hospital day 3. Emergent angiography revealed multivessel vasospasm with apparent stenoses up to 90%. Cardiac magnetic resonance showed ischemic injury without myocarditis. Repeat angiography on hospital day 20 demonstrated nonobstructive coronary artery disease, supporting vasospasm-mediated coronary pseudostenosis.Discussion Severe status asthmaticus may precipitate type 1 Kounis syndrome. Apparent coronary stenoses during active vasospasm may represent vasospasm-mediated pseudostenosis and should be reassessed before revascularization is considered.Take-home messages Severe status asthmaticus may precipitate type 1 Kounis syndrome with ST-segment elevation myocardial infarction, malignant arrhythmias, and cardiogenic shock despite nonobstructive coronary arteries. Apparent coronary stenoses during active vasospasm may represent vasospasm-mediated pseudostenosis and should be reassessed before revascularization is pursued.