Be careful what you eat and drink; Coprinic and Kounis syndrome in a patient with the Samter`s triad

Allergic reactions to chemicals, food products or even insect bites are encountered all over the world with a variety of manifestations. Symptoms range from the development of a minor rash to life threatening anaphylactic reactions. Sometimes, acute coronary syndrome (ACS) can be registered in such patients, which may have a serious impact on the course and management of the allergic reaction. Mushroom poisoning constitutes the main portion of plant toxicities in Spain. Depending on the type of mushroom, the adverse effects range from mild gastrointestinal (GI) symptoms to major cytotoxic effects resulting in organ failure and death. Coprinopsis atramentaria poisoning is rare but with serious consequences. We report a case of a 27 year old patient with a previous history of mild persistent asthma, nasal polyps and aspirin allergy that arrived to the Emergency Department with dizziness and temor after consuming beer at a party. On arrival to the hospital, the patient suddenly collapsed, with an electrocardiogram (ECG) showing ST elevation in the inferior leads and 3rd degree atrioventricular (AV) block accompanied by urticarial-like lesions. After administration of treatment, the patient and ECG abnormalities improved. A detailed medical history showed that the patient had eaten scrambled mushrooms and beer. Expert analysis demonstrated that the combined consumption of Coprinopsis atramentaria and alcoholic beverages produced a disulfiram-like reaction (Coprinic syndrome) and type I Kounis syndrome. No case like this has been previously reported.

Kounis syndrome, Coreopsis atramentaria, acute coronary syndrome

1. Goldfrank, LR. Mushrooms. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, editor. Goldfrank’s Toxicologic Emergencies. 9th ed. New York: McGraw Hill; 2010. p. 1522.

2. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila) 2009;47:911.

3. Brent, J, Palmer, RB. Mushrooms. In: Shannon, MW, Borron, SW, Burns MJ, editors. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia (PA): Saunders Elsevier; 2007. p. 455.

4. Michelot D. Poisoning by Coprinus atramentarius. Nat Toxins 1992;1:73.

5. Haberl B, Pfab R, Berndt S, Greifenhagen C, Zilker T. Case series: Alcohol intolerance with Coprine-like syndrome after consumption of the mushroom Lepiota aspera (Pers.:Fr.) Quél., 1886 (Freckled Dapperling). Clin Toxicol (Phila) 2011;49:113.

6. Pfister CW, Plice SG. Acute myocardial infarction during a prolonged allergic reaction to penicillin. Am Heart J 1950;40:945–7.

7. Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the concept of allergic angina. Br J Clin Pract 1991;45:121–8.

8. Kounis NG, Zavras GM. Allergic angina and allergic myocardial infarction. Circulation 1996;94:1789.

9. Yanagawa Y, Nishi K, Tomiharu N, Kawaguchi T. A case of takotsubo cardiomyopathy associated with Kounis syndrome. Int J Cardiol 2009;132:65-7.

10. Kounis GN, Kounis SA, Hahalis G, Kounis NG. Coronary artery spasm associated with eosinophilia: another manifestation of Kounis syndrome? Heart Lung Circ 2009;18:163-4.

11. Nikolaidis LA, Kounis NG, Grandman AH. Allergic angina and allergic

myocardial infarction: a new twist on an old syndrome. Can J Cardiol 2002;18:508–11.

12. Biteker M. A new classification of Kounis syndrome. Int J Cardiol 2010;145:553.

13. Cevik C, Nugent K, Shome GP, Kounis NG. Treatment of Kounis syndrome. Int J Cardiol 2010;143(3):223–6.