To the Editor
Professor Nicholas G Kounis and colleagues 1 are owed high appreciation for expressing their expert opinion on confirming the diagnosis of anaphylaxis and mechanisms of sudden cardiac arrest associated with acute anaphylaxis. They agree with our findings that anaphylaxis was the probable cause of the tragic of death caused by Xylocopa tranquebarica sting in our report.
The value of postmortem tryptase analysis has been highlighted as a sensitive and specific measurement to diagnose anaphylaxis. It is interesting to read their remarks on coronary artery histology: “We have recently emphasized that the heart and especially the coronary arteries should be regarded as main organs and primary target of anaphylaxis serving as a primary door through which life crosses to death.” 1 We fully agree with this statement, which is applicable to the index case where the patient died without leaving time for development of mucocutaneous and pulmonary manifestations of anaphylaxis. 2 We are aware of Kounis syndrome and have experienced this specific manifestation in hornet stings and drug allergies leading to acute coronary syndrome in Sri Lanka.3,4 In type 1 Kounis syndrome, coronary artery spasm is the mechanism of cardiac ischemia that may result in sudden cardiac arrest and death. In such events, histological examination of the coronary arteries will assist in establishing the diagnosis. In addition, undue host susceptibility to anaphylaxis has been highlighted as a possible KIT mutation. Finally, dissemination of these novel concepts will lay the foundation for development of new therapeutic agents and strategies to prevent deaths from acute anaphylaxis.