A case of sugammadex-induced coronary vasospasm: "Kounis syndrome"

Kounis syndrome is a clinical condition in which acute coronary syndrome (ACS) develops due to allergic mechanisms. We report herein a case of Kounis syndrome in which the suspected causative agent was sugammadex. A 62-year-old man was scheduled to undergo inguinal herniorrhaphy under general anesthesia. Anesthesia was induced by propofol, rocuronium, and remifentanil and maintained using desflurane. The operation was finished without trouble, and then sugammadex was administered. About 3 min after administratioa tachycardia and severe hypotension appeared with ST elevation on electrocardiogram. We suspected the occurrence of ACS and the patient was treated with vasopressor and nicorandiL Blood pressure gradually recovered from 40 to 70 mmHg after treatment The trachea was extubated because respiratory condition was good and arterial blood gas analysis showed normal data Just after extubatioa the patient complained of nausea and epigastralgia The patient was transferred to the intensive care unit No symptoms suggestive of cardiac dysfunction were observed on echocardiogram. We suspected anaphylactic shock, because he fulfilled the clinical criteria, including circulatory and gastrointestinal symptoms. Blood test for serum histamine and tryptase suggested an immunoglobulin E-mediated allergic reaction. Moreover, a skin test and basophil activating test performed 28 days postoperatively suggested sugammadexinduced anaphylaxis.