Abstract 11658: Acute Coronary Syndrome After Insect Bite: A Systematic Review

Arthropod and insect bites/stings have been associated with the development of Acute Coronary Syndrome (ACS) in prior case reports. In this systematic analysis, we review 57 reported cases of ACS in patients that were exposed to arthropods, bee stings or insect bites, and provide a summary of these findings in Table 1. We then discuss Kounis Syndrome Type 1 or Type 2 as the proposed mechanism by which myocardial ischemia develops in this subset of patients, and the implications of this diagnosis on management. Kounis Syndrome Type 1 develops due to mast cell activation and histamine release provoking vasospasms and inducing myocardia injury in the absence of underlying coronary artery disease, as demonstrated in Figure 1A. Kounis Syndrome Type 2 develops due to inflammation induced plaque rupture and subsequent thrombus formation, as demonstrated in Figure 1B. In general, Kounis Syndrome should be suspected in patient’s presenting with the appropriate exposure, an allergic or anaphylactic response and/or unremarkable coronary angiogram (specific to Type 1). Once suspected, the use of coronary artery vasodilators, antihistamines, steroids and possibly Epinephrine should be considered in management. In this review, it was discovered that approximately 50% of cases received management consistent with Kounis Syndrome (targeted to allergic/anaphylactic symptoms) with appropriate clinical response, yet only 12% received the formal diagnosis, indicating this condition is underdiagnosed. Furthermore, 40% of patients that underwent coronary angiogram did not have CAD, indicating a possible Type 1 (vasospastic) etiology of ACS that may benefit from more targeted therapy.