Kounis Syndrome Presenting with Atrial Fibrillation and Shark-Fin ST Elevation After Multiple Bee Stings in an African Patient: A Case Report

Abstract

Background: Kounis syndrome is an acute coronary syndrome triggered by allergic or hypersensitivity reactions, mediated by inflammatory cascades and mast cell activation. It can manifest as coronary vasospasm, plaque rupture, or stent thrombosis. Electrocardiographic presentations vary and may mimic ST-elevation myocardial infarction, occasionally with atypical features such as atrial fibrillation or extreme ST-segment elevation patterns. Case Presentation: We report a case of an adult African patient who developed acute chest pain, hypotension, and localized allergic manifestations (pruritus and soft tissue swelling at sting sites) following multiple bee stings. Notably, no generalized urticaria or angioedema was observed. Electrocardiography revealed atrial fibrillation with a "shark-fin" ST elevation pattern, a combination not previously reported in an African patient with Kounis syndrome suggestive of extensive myocardial ischemia. Emergent management included hydrocortisone, diphenhydramine, epinephrine infusion, and intracoronary nitroglycerin. Coronary angiography and clinical evolution supported a diagnosis of coronary vasospasm highly consistent with type I Kounis syndrome, in the absence of confirmatory biomarker testing. Discussion: Kounis syndrome remains underrecognized, particularly in low-resource settings. The coexistence of atrial fibrillation and shark-fin ST elevation is rare and represents the distinguishing novelty of this case; it may lead to misdiagnosis as primary myocardial infarction or ventricular tachycardia. The confounding role of exogenous epinephrine administered during resuscitation must be acknowledged in interpreting the angiographic findings. Allergic mediators such as histamine and leukotrienes can induce coronary vasospasm and electrical instability. Early recognition is critical, as management requires simultaneous treatment of both allergic and cardiac components. Conclusion: Kounis syndrome should be considered in patients presenting with acute coronary syndromes in the context of allergic triggers such as bee stings. The simultaneous occurrence of atrial fibrillation and shark-fin ST elevation is a rare, diagnostically challenging presentation. Prompt recognition and dual-pathway management can improve outcomes.