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A Heart Gone Bananas: Allergy-Induced Coronary Vasospasm due to Banana (Kounis Syndrome)

A Heart Gone Bananas: Allergy-Induced Coronary Vasospasm due to Banana (Kounis Syndrome) Hindawi Case Reports in Immunology Volume 2023, Article ID 5987123, 3 pages https://doi.org/10.1155/2023/5987123 Case Report A Heart Gone Bananas: Allergy-Induced Coronary Vasospasm due to Banana (Kounis Syndrome) 1 1 1,2 1,2 Lauren Reinhold , Stephen Lynch, Carl B. Lauter, Simon R. Dixon, and Andrew Aneese William Beaumont University Hospital, Royal Oak, MI, USA Oakland University William Beaumont School of Medicine, Rochester, MI, USA Correspondence should be addressed to Lauren Reinhold; lauren.reinhold@beaumont.org Received 15 March 2023; Revised 7 June 2023; Accepted 8 June 2023; Published 23 June 2023 Academic Editor: Ahmad Mansour Copyright © 2023 Lauren Reinhold et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kounis syndrome encompasses a variety of cardiovascular signs and symptoms associated with mast cell activation in the setting of allergic or hypersensitivity and anaphylactic or anaphylactoid insults. It can manifest as coronary vasospasm, coronary, or in-stent thrombosis, and acute myocardial infarction with plaque rupture. Various medications as well as foods including fish, shellfish, mushroom, kiwi, and rice pudding have been implicated as causal agents. We present what we believe to be the first documented case of Kounis syndrome manifesting as coronary vasospasm as the result of an allergy to banana. This case highlights the importance of considering allergic causes of angina and allergy referral in a patient with known atopy and an otherwise negative cardiovascular workup. It also emphasizes to consider food allergy, especially banana, as a cause of Kounis syndrome. coronaries. She was diagnosed as having variant angina with 1. Introduction vasospasm, and was started on a trial of calcium-channel Kounis syndrome is a rare cause of acute coronary syndrome blockers without symptomatic relief. Given her history of due to allergy [1]. It was first described in 1981 after intrave- atopy, she was referred to our allergy clinic about 1 year after nous histamine was injected into patients causing coronary initial work up began. Tryptase levels were checked which vasospasm [2]. It has now been divided into three variants. were found to be persistently elevated, 13.3 and 13.6 ng/mL. Multiple medications and foods have been shown to induce Allergy specific IgE testing for banana, latex, and birch were Kounis syndrome. We report the first case of Type I Kounis checked after the patient reported perioral itching and tin- syndrome due to an allergy to banana. gling with banana ingestion. Her IgE testing resulted with positivity for banana 1.31 kU/L, birch 3.02 kU/L, and latex 2. Case Report 0.43 kU/L. She had been eating multiple bananas daily as part of what she believed to be a “heart-healthy” diet. Upon A 56-year-old woman initially presented with daily, inter- discontinuing bananas from her diet, her chest pain improved mittent, substernal angina exacerbated by exertion and cool dramatically both in severity and frequency. Multiple tryptase temperatures. Her angina was only relieved with sublingual levels taken after the discontinuation of bananas have been nitroglycerin, which she used up to 10 times daily. She has a within normal range, 8.4 and 8.1 ng/mL, and she has remained past medical history of asthma, severe contrast allergy and free of chest pain. allergies to multiple medications, and a remote history of Hodgkin’s. Her family history is significant for atopy, asthma, 3. Discussion and coronary artery disease. Initial cardiac workups included negative troponin levels and normal electrocardiograms. A Kounis syndrome is the occurrence of an acute coronary stress test showed anterolateral ECG changes but no perfusion syndrome that arises in conjunction with hypersensitivity, defects on imaging. Coronary catheterization revealed normal allergic, anaphylactic, or anaphylactoid reactions [1, 3]. The 2 Case Reports in Immunology association of histamine release in allergic reactions and cor- after eating banana [5]. There has been evidence of cross- onary vasospasm was first described in 1981 after injection of reacting allergens in latex and banana, but most incidents of intravenous histamine in patients with nonobstructive coro- banana allergy have been related proflin susceptibility with nary artery disease produced coronary artery spasm in 4 out banana-latex association being less common [5]. Notably, of 12 patients [2]. In 2016, Kounis defined three different our patient described symptoms of oral allergy syndrome variants [1, 3]. Type I Kounis syndrome occurs in patients and had positive IgE to latex and birch along with banana. without underlying coronary artery disease and manifests as Currently, there are no treatments or cure for banana allergy. chest pain from coronary vasospasm. Type II occurs in Processing procedures such as steam boiling, microwave heat- patients with underlying coronary artery disease and mani- ing, enzyme treatment, and ethylene treatment help to reduce fests as an acute myocardial infarction. Type III manifests as banana allergenicity, but need to be enhanced and further in-stent thrombosis and can be further divided into Type IIIa: studied [5]. Current management is based on complete avoid- stent thrombosis due to allergy and Type IIIb: stent restenosis ance after the allergen has been identified. due to allergy. These variants of Kounis syndrome occur in We believe this to be the first case of Kounis syndrome 72.6%, 22.3%, and 5.1% of patients, respectively [3]. Despite due to banana allergy. Our patient underwent workup of the clinical implications surrounding this entity, Kounis syn- her chest pain for over 1 year prior to allergy referral, testing drome is likely underrecognized and underdiagnosed. and subsequent diagnosis. Removal of the offending agent The pathophysiology behind this syndrome predomi- resulted in cessation of her anginal symptoms. In Type II and III, early detection of Kounis syndrome could have signifi- nately involves mast cells and their interaction with other immune cells [1]. During an allergic reaction, mast cell cant impact on morbidity and mortality. This case highlights the importance of considering allergic causes of angina and degranulation and inflammatory mediator release occurs. It allergy referral in an atopic patient with chest pain. It also has been speculated that the heart and coronary arteries emphasizes the importance of a complete history of present might be the primary target of allergic or anaphylactic reac- illness and to consider food allergy, especially banana, as a tions [4]. The effects of these mediators may lead to serious cause of Kounis syndrome. cardiac events including chest pain, ECG changes, arrhyth- mias, and even myocardial ischemia and infarction. Various triggers of Kounis syndrome have been described in recent Data Availability years. The most common causes include medications, mainly The data used to support the findings of this study are avail- antibiotics or anti-inflammatory drugs. Environmental anti- able from thecorresponding author upon request. gens and insect bites have also been implicated [1, 3]. Although uncommon, food-related triggers have also been described. These food triggers include ingestion of certain raw or under- Disclosure cooked fish, scombroid poisoning from spoiled fish, shellfish, This case report was previously presented as a poster at gelofusin substance, mushroom, rice milk, kiwifruit, tomato the AAAAI/WAO Joint Congress Meeting in March 2018. salad, and certain nuts [1, 3]. To our knowledge, Kounis syn- drome related to banana ingestion has not been previously reported. Conflicts of Interest In the general population, banana fruit is an uncommon The authors declare that they have no conflicts of interest. cause of allergy, affecting around 0.6% of people [5]. In atopic individuals, it has been shown to cause allergy more commonly. Banana fruit allergy results from an abnormal References immune response to banana proteins with six major proteins [1] N. G. Kounis, “Kounis syndrome: an update on epidemiology, identified: Mus a1 (proflin-actin binding protein), Mus a 2 pathogenesis, diagnosis and therapeutic management,” Clinical (Class 1 chitinase), Mus a 3 (nonspecifc lipid transfer pro- Chemistry and Laboratory Medicine (CCLM), vol. 54, no. 10, tein), Mus a 4 (thaumatin-like protein), Mus a 5 (beta 1,3 pp. 1545–1559, 2016. glucanase), and Mus a 6 (ascorbate peroxidase) [5]. Multiple [2] R. Ginsburg, M. R. Bristow, N. Kantrowitz, D. S. Baim, and different proteins have been associated with IgE reactivity D. C. Harrison, “Histamine provocation of clinical coronary leading to mast and basophil cell activation. This causes artery spasm: implications concerning pathogenesis of variant secretion of histamine, tryptase, and chymase which leads angina pectoris,” American Heart Journal,vol. 102,no. 5, pp. 819–822, 1981. to a variety of physiologic responses. [3] M. Abdelghany, R. Subedi, S. Shah, and H. Kozman, “Kounis Hypersensitivity reactions to banana have also been asso- syndrome: a review article on epidemiology, diagnostic findings, ciated with birch pollen and latex allergies [5]. In some patients management and complications of allergic acute coronary allergic to birch pollen, upon eating banana can develop itch- syndrome,” International Journal of Cardiology,vol. 232,pp. 1–4, ing and inflammation of the mouth and throat called oral allergy syndrome. The Mus a 1 gene in banana was found [4] N. G. Kounis, G. Cervellin, I. Koniari et al., “Anaphylactic to be the most notable mediator for the IgE cross-reactions cardiovascular collapse and Kounis syndrome: systemic vasodilation between the pollen and banana [5]. Nearly 20%–50% of people or coronary vasoconstriction?” Annals of Translational Medicine, with natural rubber latex allergy have shown hypersensitivity vol. 6, no. 17, Article ID 332, 2018. Case Reports in Immunology 3 [5] P. Suriyamoorthy, A. Madhuri, S. Tangirala et al., “Compre- hensive review on banana fruit allergy: pathogenesis, diagnosis, management, and potential modification of allergens through food processing,” Plant Foods for Human Nutrition, vol. 77, pp. 159–171, 2022. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Immunology Hindawi Publishing Corporation

A Heart Gone Bananas: Allergy-Induced Coronary Vasospasm due to Banana (Kounis Syndrome)

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Hindawi Publishing Corporation
ISSN
2090-6609
eISSN
2090-6617
DOI
10.1155/2023/5987123
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Abstract

Hindawi Case Reports in Immunology Volume 2023, Article ID 5987123, 3 pages https://doi.org/10.1155/2023/5987123 Case Report A Heart Gone Bananas: Allergy-Induced Coronary Vasospasm due to Banana (Kounis Syndrome) 1 1 1,2 1,2 Lauren Reinhold , Stephen Lynch, Carl B. Lauter, Simon R. Dixon, and Andrew Aneese William Beaumont University Hospital, Royal Oak, MI, USA Oakland University William Beaumont School of Medicine, Rochester, MI, USA Correspondence should be addressed to Lauren Reinhold; lauren.reinhold@beaumont.org Received 15 March 2023; Revised 7 June 2023; Accepted 8 June 2023; Published 23 June 2023 Academic Editor: Ahmad Mansour Copyright © 2023 Lauren Reinhold et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kounis syndrome encompasses a variety of cardiovascular signs and symptoms associated with mast cell activation in the setting of allergic or hypersensitivity and anaphylactic or anaphylactoid insults. It can manifest as coronary vasospasm, coronary, or in-stent thrombosis, and acute myocardial infarction with plaque rupture. Various medications as well as foods including fish, shellfish, mushroom, kiwi, and rice pudding have been implicated as causal agents. We present what we believe to be the first documented case of Kounis syndrome manifesting as coronary vasospasm as the result of an allergy to banana. This case highlights the importance of considering allergic causes of angina and allergy referral in a patient with known atopy and an otherwise negative cardiovascular workup. It also emphasizes to consider food allergy, especially banana, as a cause of Kounis syndrome. coronaries. She was diagnosed as having variant angina with 1. Introduction vasospasm, and was started on a trial of calcium-channel Kounis syndrome is a rare cause of acute coronary syndrome blockers without symptomatic relief. Given her history of due to allergy [1]. It was first described in 1981 after intrave- atopy, she was referred to our allergy clinic about 1 year after nous histamine was injected into patients causing coronary initial work up began. Tryptase levels were checked which vasospasm [2]. It has now been divided into three variants. were found to be persistently elevated, 13.3 and 13.6 ng/mL. Multiple medications and foods have been shown to induce Allergy specific IgE testing for banana, latex, and birch were Kounis syndrome. We report the first case of Type I Kounis checked after the patient reported perioral itching and tin- syndrome due to an allergy to banana. gling with banana ingestion. Her IgE testing resulted with positivity for banana 1.31 kU/L, birch 3.02 kU/L, and latex 2. Case Report 0.43 kU/L. She had been eating multiple bananas daily as part of what she believed to be a “heart-healthy” diet. Upon A 56-year-old woman initially presented with daily, inter- discontinuing bananas from her diet, her chest pain improved mittent, substernal angina exacerbated by exertion and cool dramatically both in severity and frequency. Multiple tryptase temperatures. Her angina was only relieved with sublingual levels taken after the discontinuation of bananas have been nitroglycerin, which she used up to 10 times daily. She has a within normal range, 8.4 and 8.1 ng/mL, and she has remained past medical history of asthma, severe contrast allergy and free of chest pain. allergies to multiple medications, and a remote history of Hodgkin’s. Her family history is significant for atopy, asthma, 3. Discussion and coronary artery disease. Initial cardiac workups included negative troponin levels and normal electrocardiograms. A Kounis syndrome is the occurrence of an acute coronary stress test showed anterolateral ECG changes but no perfusion syndrome that arises in conjunction with hypersensitivity, defects on imaging. Coronary catheterization revealed normal allergic, anaphylactic, or anaphylactoid reactions [1, 3]. The 2 Case Reports in Immunology association of histamine release in allergic reactions and cor- after eating banana [5]. There has been evidence of cross- onary vasospasm was first described in 1981 after injection of reacting allergens in latex and banana, but most incidents of intravenous histamine in patients with nonobstructive coro- banana allergy have been related proflin susceptibility with nary artery disease produced coronary artery spasm in 4 out banana-latex association being less common [5]. Notably, of 12 patients [2]. In 2016, Kounis defined three different our patient described symptoms of oral allergy syndrome variants [1, 3]. Type I Kounis syndrome occurs in patients and had positive IgE to latex and birch along with banana. without underlying coronary artery disease and manifests as Currently, there are no treatments or cure for banana allergy. chest pain from coronary vasospasm. Type II occurs in Processing procedures such as steam boiling, microwave heat- patients with underlying coronary artery disease and mani- ing, enzyme treatment, and ethylene treatment help to reduce fests as an acute myocardial infarction. Type III manifests as banana allergenicity, but need to be enhanced and further in-stent thrombosis and can be further divided into Type IIIa: studied [5]. Current management is based on complete avoid- stent thrombosis due to allergy and Type IIIb: stent restenosis ance after the allergen has been identified. due to allergy. These variants of Kounis syndrome occur in We believe this to be the first case of Kounis syndrome 72.6%, 22.3%, and 5.1% of patients, respectively [3]. Despite due to banana allergy. Our patient underwent workup of the clinical implications surrounding this entity, Kounis syn- her chest pain for over 1 year prior to allergy referral, testing drome is likely underrecognized and underdiagnosed. and subsequent diagnosis. Removal of the offending agent The pathophysiology behind this syndrome predomi- resulted in cessation of her anginal symptoms. In Type II and III, early detection of Kounis syndrome could have signifi- nately involves mast cells and their interaction with other immune cells [1]. During an allergic reaction, mast cell cant impact on morbidity and mortality. This case highlights the importance of considering allergic causes of angina and degranulation and inflammatory mediator release occurs. It allergy referral in an atopic patient with chest pain. It also has been speculated that the heart and coronary arteries emphasizes the importance of a complete history of present might be the primary target of allergic or anaphylactic reac- illness and to consider food allergy, especially banana, as a tions [4]. The effects of these mediators may lead to serious cause of Kounis syndrome. cardiac events including chest pain, ECG changes, arrhyth- mias, and even myocardial ischemia and infarction. Various triggers of Kounis syndrome have been described in recent Data Availability years. The most common causes include medications, mainly The data used to support the findings of this study are avail- antibiotics or anti-inflammatory drugs. Environmental anti- able from thecorresponding author upon request. gens and insect bites have also been implicated [1, 3]. Although uncommon, food-related triggers have also been described. These food triggers include ingestion of certain raw or under- Disclosure cooked fish, scombroid poisoning from spoiled fish, shellfish, This case report was previously presented as a poster at gelofusin substance, mushroom, rice milk, kiwifruit, tomato the AAAAI/WAO Joint Congress Meeting in March 2018. salad, and certain nuts [1, 3]. To our knowledge, Kounis syn- drome related to banana ingestion has not been previously reported. Conflicts of Interest In the general population, banana fruit is an uncommon The authors declare that they have no conflicts of interest. cause of allergy, affecting around 0.6% of people [5]. In atopic individuals, it has been shown to cause allergy more commonly. Banana fruit allergy results from an abnormal References immune response to banana proteins with six major proteins [1] N. G. Kounis, “Kounis syndrome: an update on epidemiology, identified: Mus a1 (proflin-actin binding protein), Mus a 2 pathogenesis, diagnosis and therapeutic management,” Clinical (Class 1 chitinase), Mus a 3 (nonspecifc lipid transfer pro- Chemistry and Laboratory Medicine (CCLM), vol. 54, no. 10, tein), Mus a 4 (thaumatin-like protein), Mus a 5 (beta 1,3 pp. 1545–1559, 2016. glucanase), and Mus a 6 (ascorbate peroxidase) [5]. Multiple [2] R. Ginsburg, M. R. Bristow, N. Kantrowitz, D. S. Baim, and different proteins have been associated with IgE reactivity D. C. Harrison, “Histamine provocation of clinical coronary leading to mast and basophil cell activation. This causes artery spasm: implications concerning pathogenesis of variant secretion of histamine, tryptase, and chymase which leads angina pectoris,” American Heart Journal,vol. 102,no. 5, pp. 819–822, 1981. to a variety of physiologic responses. [3] M. Abdelghany, R. Subedi, S. Shah, and H. Kozman, “Kounis Hypersensitivity reactions to banana have also been asso- syndrome: a review article on epidemiology, diagnostic findings, ciated with birch pollen and latex allergies [5]. In some patients management and complications of allergic acute coronary allergic to birch pollen, upon eating banana can develop itch- syndrome,” International Journal of Cardiology,vol. 232,pp. 1–4, ing and inflammation of the mouth and throat called oral allergy syndrome. The Mus a 1 gene in banana was found [4] N. G. Kounis, G. Cervellin, I. Koniari et al., “Anaphylactic to be the most notable mediator for the IgE cross-reactions cardiovascular collapse and Kounis syndrome: systemic vasodilation between the pollen and banana [5]. Nearly 20%–50% of people or coronary vasoconstriction?” Annals of Translational Medicine, with natural rubber latex allergy have shown hypersensitivity vol. 6, no. 17, Article ID 332, 2018. Case Reports in Immunology 3 [5] P. Suriyamoorthy, A. Madhuri, S. Tangirala et al., “Compre- hensive review on banana fruit allergy: pathogenesis, diagnosis, management, and potential modification of allergens through food processing,” Plant Foods for Human Nutrition, vol. 77, pp. 159–171, 2022.

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Case Reports in ImmunologyHindawi Publishing Corporation

Published: Jun 23, 2023

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