{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,25]],"date-time":"2026-04-25T10:57:13Z","timestamp":1777114633002,"version":"3.51.4"},"reference-count":17,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2026,3,13]],"date-time":"2026-03-13T00:00:00Z","timestamp":1773360000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,4,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or hypersensitivity reactions and is classified into three variants: coronary vasospasm, plaque rupture, and stent thrombosis. Type III KS involving stent thrombosis is extremely rare. The mechanisms linking allergic triggers with very late stent thrombosis (VLST) remain insufficiently characterized.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case summary<\/jats:title>\n                    <jats:p>We present a rare case of Type III KS triggered by contrast media in a 74-year-old man with a history of everolimus-eluting stent implantation \u223c1 year and 10 months prior to presentation and chronic corticosteroid therapy for membranous nephropathy. Shortly after a contrast-enhanced computed tomography scan, the patient developed an ST-elevated myocardial infarction. Optical frequency-domain imaging revealed a heavy thrombus burden, malapposed stent struts, and uncovered struts. The drug-induced lymphocyte stimulation test was positive for iopamidol, confirming contrast-induced KS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This case highlights the potential interplay between mechanical vulnerability (malapposition and uncovered struts) and allergic responses in the pathogenesis of VLST. Chronic corticosteroid therapy may have delayed vascular healing, contributing to persistent uncovered struts. The combination of stent-related factors and systemic hypersensitivity likely promoted thrombus formation. Physicians should consider KS in the differential diagnosis of stent thrombosis even if it occurs long after percutaneous coronary intervention or if the patient is receiving long-term corticosteroid therapy.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytag199","type":"journal-article","created":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T15:52:59Z","timestamp":1773330779000},"source":"Crossref","is-referenced-by-count":1,"title":["Very late stent thrombosis associated with stent malapposition and uncovered struts after contrast-enhanced CT in a patient receiving long-term steroid therapy due to Kounis syndrome: a case report"],"prefix":"10.1093","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-7822-5399","authenticated-orcid":false,"given":"Yuichiro","family":"Tomida","sequence":"first","affiliation":[{"name":"Department of Cardiology, Seirei Mikatahara General Hospital , 3453 Mikatahara-cho, Chuo-ku, Hamamatsu-city, Shizuoka 433-8558 ,","place":["Japan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yoshitaka","family":"Kawaguchi","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Seirei Mikatahara General Hospital , 3453 Mikatahara-cho, Chuo-ku, Hamamatsu-city, Shizuoka 433-8558 ,","place":["Japan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5999-7747","authenticated-orcid":false,"given":"Keisuke","family":"Miyajima","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Seirei Mikatahara General Hospital , 3453 Mikatahara-cho, Chuo-ku, Hamamatsu-city, Shizuoka 433-8558 ,","place":["Japan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yasushi","family":"Wakabayashi","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Seirei Mikatahara General Hospital , 3453 Mikatahara-cho, Chuo-ku, Hamamatsu-city, Shizuoka 433-8558 ,","place":["Japan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yuichiro","family":"Maekawa","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine , 1-20-1 Handayama, Chuo-ku, Hamamatsu-city, Shizuoka 431-3192 ,","place":["Japan"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,3,13]]},"reference":[{"key":"2026041704180789400_ytag199-B1","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1111\/j.1742-1241.1991.tb10251.x","article-title":"Histamine-induced coronary artery spasm: the concept of allergic angina","volume":"45","author":"Kounis","year":"1991","journal-title":"Br J Clin Pract"},{"key":"2026041704180789400_ytag199-B2","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ijcard.2017.01.124","article-title":"Kounis syndrome: a review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome","volume":"232","author":"Abdelghany","year":"2017","journal-title":"Int J Cardiol"},{"key":"2026041704180789400_ytag199-B3","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1016\/j.jcin.2009.04.017","article-title":"Drug-eluting stent thrombosis: the Kounis hypersensitivity-associated acute coronary syndrome revisited","volume":"2","author":"Chen","year":"2009","journal-title":"JACC Cardiovasc Interv"},{"key":"2026041704180789400_ytag199-B4","doi-asserted-by":"crossref","first-page":"1545","DOI":"10.1515\/cclm-2016-0010","article-title":"Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management","volume":"54","author":"Kounis","year":"2016","journal-title":"Clin Chem Lab Med"},{"key":"2026041704180789400_ytag199-B5","doi-asserted-by":"crossref","first-page":"38","DOI":"10.3390\/vaccines10010038","article-title":"Allergy associated myocardial infarction: a comprehensive report of clinical presentation, diagnosis and management of Kounis syndrome","volume":"10","author":"Roumeliotis","year":"2021","journal-title":"Vaccines (Basel)"},{"key":"2026041704180789400_ytag199-B6","doi-asserted-by":"crossref","first-page":"3720","DOI":"10.1093\/eurheartj\/ehad191","article-title":"2023 ESC guidelines for the management of acute coronary syndromes","volume":"44","author":"Byrne","year":"2023","journal-title":"Eur Heart J"},{"key":"2026041704180789400_ytag199-B7","doi-asserted-by":"crossref","first-page":"3320","DOI":"10.1093\/eurheartj\/ehv511","article-title":"Stent thrombosis and restenosis: what have we learned and where are we going? 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