Diclofenac
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Diclofenac Recurrent Kounis syndrome manifested as allergic myocardial infarction with ST-segment elevation and coronary spasm: case report
A middle-aged woman [age not stated] developed recurrent Kounis syndrome manifested as allergic myocardial infarction with ST-segment elevation (STEMI) and coronary spasm following treatment with diclofenac for myalgia, headache and ear pain. The woman presented at the emergency department with general muscular pain (myalgia) and weakness. Two years prior to the presentation, she had developed a myocardial infarction. She also had a history of bronchial asthma, hypertension and intermittent smoking. She did not have any history of Prinzmetal’s angina pectoris. She had been taking ramipril, aspirin and unspecified bronchodilators whenever needed. In the emergency department, she was administered IM injection of diclofenac [diclofenac sodium; dose not stated] for myalgia. Five hours after the administration of diclofenac, she developed squeezing chest pain, sweating and nausea without allergic reactions such as pruritus, erythema, urticaria and bronchospasm. Shortly after chest pain, her medical situation got worsened and her BP was 60/40mm Hg and heart rate was 38 beats/min. Her skin was cold and sweaty. The examination of cardiac and other systems was unremarkable except findings mentioned above. An ECG showed prominent STsegment elevations in leads II, III-aVF and V5–6, and ST-segment depression in leads aVL and V1–3 with atrioventricular (AV) complete block leading to cardiogenic shock. She was treated with atropine and sodium chloride [saline]. The AV block subsequently resolved and BP increased to 110/70mm Hg, but ST elevation in inferior leads continued. Acute infero-posterior STEMI was considered. She received morphine [morphine sulfate] and aspirin. She was then taken to catheter laboratory for primary percutaneous coronary intervention. A coronary angiography showed dominant left circumflex artery with non-significant plaque and left anterior descending artery with normal appearance. Right coronary artery was non-dominant without a fixed stenosis. It was considered that the non-significant plaque in the left circumflex artery and right coronary artery were not responsible for the acute inferior-posterior STEMI. At the same time, her chest pain was relieved and ST elevation was resolved in the ECG. She was considered to have a possible diclofenac-induced vasospastic STEMI. The woman received treatment with enoxaparin sodium [enoxaparin], clopidogrel, diltiazem and aspirin. Initial cardiac troponin I was normal, but it was elevated at 6h. Other routine biochemical tests were normal except blood sugar (131 mg/dL) and low-density lipoprotein cholesterol (98 mg/dL). Her WBC count was slightly high and eosinophilia (6%) was present in peripheral smear. An echocardiography revealed an ejection fraction of 60% and mild hypokinesia in mid segment of inferior wall of the left ventricle. After taking detailed medical history, it was found that she had experienced acute anter
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