{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T01:03:41Z","timestamp":1784595821180,"version":"3.55.0"},"reference-count":14,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T00:00:00Z","timestamp":1779753600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T00:00:00Z","timestamp":1784592000000},"content-version":"vor","delay-in-days":56,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["JA Clin Rep"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Kounis syndrome (KS) is an allergic acute coronary syndrome that may precipitate severe perioperative cardiovascular collapse. This study reports a case of remimazolam-induced refractory anaphylaxis complicated by KS and successfully treated with early extracorporeal cardiopulmonary resuscitation (ECPR).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>A 69-year-old male with atrial fibrillation was scheduled for lung resection. After induction of anesthesia with remimazolam, he developed abrupt tachycardia, coughing, and circulatory collapse with ST-segment elevation. Despite repeated adrenaline doses, he progressed to cardiac arrest. Venoarterial extracorporeal membrane oxygenation was initiated during cardiopulmonary resuscitation. Return of spontaneous circulation occurred 15\u00a0min after the cardiac arrest. The patient recovered without neurological sequelae. Elevated serum tryptase levels (49.5\u00a0\u00b5g\/L; 24-h postonset: 4.5\u00a0\u00b5g\/L) and positive intradermal testing suggested remimazolam-induced anaphylaxis. Coronary computed tomography revealed no stenosis, compatible with suspected type 1 KS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Remimazolam-induced anaphylaxis may be complicated by suspected KS. In refractory anaphylaxis complicated by cardiac arrest, early ECPR may be critical to survival.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s40981-026-00862-8","type":"journal-article","created":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T04:05:12Z","timestamp":1779768312000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Refractory remimazolam-induced anaphylaxis and suspected Kounis syndrome requiring extracorporeal cardiopulmonary resuscitation: a case report"],"prefix":"10.1186","volume":"12","author":[{"given":"Hajime","family":"Kotsubo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takumi","family":"Taniguchi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,26]]},"reference":[{"key":"862_CR1","doi-asserted-by":"publisher","first-page":"1545","DOI":"10.1515\/cclm-2016-0010","volume":"54","author":"NG Kounis","year":"2016","unstructured":"Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis, and therapeutic management. Clin Chem Lab Med. 2016;54:1545\u201359.","journal-title":"Clin Chem Lab Med"},{"key":"862_CR2","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.ijcard.2017.01.124","volume":"232","author":"M Abdelghany","year":"2017","unstructured":"Abdelghany M, Subedi R, Shah S, Kozman H. Kounis syndrome: a review article on epidemiology, diagnostic findings, management, and complications of allergic acute coronary syndrome. Int J Cardiol. 2017;232:1\u20134.","journal-title":"Int J Cardiol"},{"key":"862_CR3","doi-asserted-by":"publisher","first-page":"S578","DOI":"10.1161\/CIR.0000000000001380","volume":"152","author":"D Cao","year":"2025","unstructured":"Cao D, Arens AM, Chow SL, Easter SR, Hoffman RS, Lagina AT, et al. Part 10: adult and pediatric special circumstances of resuscitation: 2025 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025;152:S578-672.","journal-title":"Circulation"},{"key":"862_CR4","doi-asserted-by":"publisher","first-page":"2070","DOI":"10.1053\/j.jvca.2022.01.042","volume":"36","author":"B Dai","year":"2022","unstructured":"Dai B, Cavaye J, Judd M, Beuth J, Iswariah H, Gurunathan U. Perioperative presentations of Kounis syndrome: a systematic literature review. J Cardiothorac Vasc Anesth. 2022;36:2070\u20136.","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"862_CR5","doi-asserted-by":"publisher","first-page":"e122","DOI":"10.1016\/j.bja.2022.07.047","volume":"129","author":"KM Kim","year":"2022","unstructured":"Kim KM, Lee H, Bang JY, Choi B-M, Noh GJ. Anaphylaxis following remimazolam administration during induction of anaesthesia. Br J Anaesth. 2022;129:e122\u20134.","journal-title":"Br J Anaesth"},{"key":"862_CR6","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1016\/j.ijcard.2019.06.002","volume":"292","author":"R Desai","year":"2019","unstructured":"Desai R, Parekh T, Patel U, Fong HK, Samani S, Patel C, et al. Epidemiology of acute coronary syndrome co-existent with allergic\/hypersensitivity\/anaphylactic reactions (Kounis syndrome) in the United States: a nationwide inpatient analysis. Int J Cardiol. 2019;292:35\u20138.","journal-title":"Int J Cardiol"},{"key":"862_CR7","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1111\/cea.14434","volume":"54","author":"G Pouessel","year":"2024","unstructured":"Pouessel G, Tacquard C, Tanno LK, Mertes PM, Lezmi G. Anaphylaxis mortality in the perioperative setting: epidemiology, elicitors, risk factors and knowledge gaps. Clin Exp Allergy. 2024;54:11\u201320.","journal-title":"Clin Exp Allergy"},{"key":"862_CR8","doi-asserted-by":"publisher","first-page":"11","DOI":"10.2174\/187152809787582462","volume":"8","author":"M Ridella","year":"2009","unstructured":"Ridella M, Bagdure S, Nugent K, Cevik C. Kounis syndrome following beta-lactam antibiotic use: review of literature. Inflamm Allergy Drug Targets. 2009;8:11\u20136.","journal-title":"Inflamm Allergy Drug Targets"},{"key":"862_CR9","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1159\/000087641","volume":"87","author":"LJ Kay","year":"2005","unstructured":"Kay LJ, Peachell PT. Mast cell beta2-adrenoceptors. Chem Immunol Allergy. 2005;87:145\u201353.","journal-title":"Chem Immunol Allergy"},{"key":"862_CR10","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1016\/j.ijcard.2010.02.040","volume":"143","author":"C Cevik","year":"2010","unstructured":"Cevik C, Nugent K, Shome GP, Kounis NG. Treatment of Kounis syndrome. 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