{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T22:32:32Z","timestamp":1788561152352,"version":"build-2803163510"},"reference-count":64,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2023,1,19]],"date-time":"2023-01-19T00:00:00Z","timestamp":1674086400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Kounis syndrome is a multisystem and multidisciplinary disease affecting the circulatory system that can be manifested as spasm and thrombosis. It can occur as allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions associated with the release of inflammatory mediators from mast cells and from other interrelated and interacting inflammatory cells, including macrophages and lymphocytes. A platelet subset with high- and low-affinity IgE surface receptors is also involved in this process. Whereas the heart, and particularly the coronary arteries, constitute the primary targets of inflammatory mediators, the mesenteric, cerebral, and peripheral arteries are also vulnerable. Kounis syndrome is caused by a variety of factors, including drugs, foods, environmental exposure, clinical conditions, stent implantation, and vaccines. We report a unique case of a 60-year-old male with a past medical history of allergy to human albumin, alcoholic cirrhosis, and esophageal varices, who was admitted due to multiple episodes of hematemesis. Due to low hemoglobin levels, he was transfused with 3 units of red blood cells and fresh frozen plasma without any adverse reactions. On the third day of hospitalization, severe thrombocytopenia was observed and transfusion of platelets was initiated. Immediately following platelet infusion, the patient developed chest discomfort, skin signs of severe allergic reaction, and hemodynamic instability. The electrocardiogram revealed ST segment elevation in the inferior leads. Given the strong suspicion of Kounis syndrome\/allergic coronary spasm, the patient was treated with anti-allergic treatment only, without any anti-platelet therapy. The clinical status of the patient gradually improved and the electrocardiographic changes reverted to normal. Based on these findings, Kounis hypersensitivity-associated acute coronary syndrome, specifically, type I Kounis syndrome, was diagnosed. Although platelet transfusion can be a life-saving therapy, each blood transfusion carries a substantial risk of adverse reactions. The aims of this report are to expand the existing knowledge of patient responses to blood transfusion and provide information on the incidence of various severe transfusion reactions to all blood components and especially to platelets. To the best of our knowledge, Kounis syndrome induced by platelet transfusionhas never been previously reported. Hypersensitivity to platelet external membrane glycoproteins in an atopic patient seems to be the possible etiology. Despite that Kounis syndrome remains an under-diagnosed clinical entity in everyday practice, it should always be considered in the differential diagnosis of acute coronary syndromes.<\/jats:p>","DOI":"10.3390\/vaccines11020220","type":"journal-article","created":{"date-parts":[[2023,1,19]],"date-time":"2023-01-19T06:22:10Z","timestamp":1674109330000},"page":"220","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Blood Transfusion Components Inducing Severe Allergic Reactions: The First Case of Kounis Syndrome Induced by Platelet Transfusion"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9598-6954","authenticated-orcid":false,"given":"Christos","family":"Gogos","sequence":"first","affiliation":[{"name":"Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Konstantinos","family":"Stamos","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6251-0781","authenticated-orcid":false,"given":"Nikolaos","family":"Tsanaxidis","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioannis","family":"Styliadis","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Papageorgiou General Hospital, Nea Efkarpia, 56403 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioanna","family":"Koniari","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sophia N.","family":"Kouni","sequence":"additional","affiliation":[{"name":"Speech Therapy Practice, 26221 Patras, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3022-266X","authenticated-orcid":false,"given":"Cesare","family":"de Gregorio","sequence":"additional","affiliation":[{"name":"Department of Clinical and Experimental Medicine, University of Messina Medical School, 98122 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9751-6710","authenticated-orcid":false,"given":"Nicholas G.","family":"Kounis","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Cardiology, University of Patras Medical School, 26221 Patras, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,1,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"169","DOI":"10.7861\/futurehosp.3-3-169","article-title":"Challenging blood transfusion practice: Effect of targeted behavioural intervention on red cell transfusion in a district general hospital","volume":"3","author":"Warburton","year":"2016","journal-title":"Future Hosp. J."},{"key":"ref_2","first-page":"378","article-title":"Myocardial infarction following blood transfusion","volume":"40","author":"Shadaksharappa","year":"1963","journal-title":"J. Indian Med. Assoc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"400","DOI":"10.3143\/geriatrics.13.400","article-title":"Reversible myocardial infarction in the aged following blood transfusion","volume":"13","author":"Kuramoto","year":"1976","journal-title":"Nihon Ronen Igakkai Zasshi"},{"key":"ref_4","first-page":"279","article-title":"Ischaemic electrocardiographic changes after massive blood transfusion: Findings based on myocardial scintigraphy using 99mTc-MIBI and 123I-MIBG","volume":"53","author":"Kondo","year":"1998","journal-title":"Acta Cardiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1016\/j.transci.2014.01.009","article-title":"Acute myocardial infarction associated with blood transfusion: Case report and literature review","volume":"50","author":"Velibey","year":"2014","journal-title":"Transfus. Apher. Sci."},{"key":"ref_6","unstructured":"Wadell, L.A. (1930). Egyptian Civilization it\u2019s Sumerian Original and Real Chronology, Luzac & Co."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1234","DOI":"10.1111\/j.1398-9995.2004.00603.x","article-title":"Pharaoh Menes\u2019 death after an anaphylactic reaction the end of a myth","volume":"59","author":"Krombach","year":"2004","journal-title":"Allergy"},{"key":"ref_8","unstructured":"Howell, W.H. (1903). Contributions to Medical Research, Dedicated to Victor Clarence Vaughan."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1084\/jem.14.5.476","article-title":"Lethal cardiac anaphylaxis in the rabbit","volume":"14","author":"Auer","year":"1911","journal-title":"J. Exp. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1098","DOI":"10.1001\/jama.1938.62790140001008","article-title":"Serum carditis: Morphologic cardiac alterations in man associated with serum disease","volume":"110","author":"Clark","year":"1938","journal-title":"J. Am. Med. Assoc."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1016\/S0022-3476(40)80025-5","article-title":"Serum reaction complicated by acute carditis","volume":"17","author":"Wadsworth","year":"1940","journal-title":"J. Pediatr."},{"key":"ref_12","first-page":"239","article-title":"Experimental evidence that lesions with basic characteristics of rheumatic carditis can result from anaphylactic hypersensitivity","volume":"73","author":"Rich","year":"1943","journal-title":"Bull. Johns Hopkins Hosp."},{"key":"ref_13","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":"ref_14","doi-asserted-by":"crossref","first-page":"622","DOI":"10.1111\/j.1742-1241.2003.tb10570.x","article-title":"Kounis syndrome secondary to allergic reaction following shellfish ingestion","volume":"57","author":"Zavras","year":"2003","journal-title":"Int. J. Clin. Pract."},{"key":"ref_15","first-page":"1612","article-title":"Is vasospastic angina an inflammatory disease?","volume":"96","author":"Rich","year":"2005","journal-title":"Am. J. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"212","DOI":"10.4274\/balkanmedj.galenos.2019.2019.5.62","article-title":"Kounis Syndrome-not a single-organ arterial disorder but a multisystem and multidisciplinary disease","volume":"36","author":"Kounis","year":"2019","journal-title":"Balkan Med. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"145","DOI":"10.5152\/balkanmedj.2021.21097","article-title":"COVID-19 and Kounis Syndrome: Deciphering Their Relationship","volume":"38","author":"Kounis","year":"2021","journal-title":"Balkan Med. J."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"3018","DOI":"10.1093\/eurheartj\/ehaa548","article-title":"Mast cell tryptase level should be checked in all patients with suspected Kounis syndrome","volume":"41","author":"Khan","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1016\/j.anai.2020.07.007","article-title":"The impact of psychological stress on mast cells","volume":"125","author":"Theoharides","year":"2020","journal-title":"Ann. Allergy Asthma Immunol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1159\/000053852","article-title":"A comparison of Fcepsilon RI-mediated RANTES release from human platelets between allergic patients and healthy individuals","volume":"125","author":"Hasegawa","year":"2001","journal-title":"Int. Arch. Allergy Immunol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2543","DOI":"10.1182\/blood.V93.8.2543","article-title":"Functional expression of the high affinity receptor for IgE (FcepsilonRI) in human platelets and its\u2019 intracellular expression in human megakaryocytes","volume":"93","author":"Hasegawa","year":"1999","journal-title":"Blood"},{"key":"ref_22","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":"ref_23","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1186\/s12948-021-00149-6","article-title":"The blocking effect of the glycoprotein IIb\/IIIa receptor in the mouse model of asthma","volume":"19","author":"Kim","year":"2021","journal-title":"Clin. Mol. Allergy"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.alit.2015.06.001","article-title":"Allergens, sources, particles, and molecules: Why do we make IgE responses?","volume":"64","author":"Woodfolk","year":"2015","journal-title":"Allergol. Int."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1791","DOI":"10.1016\/S0140-6736(13)60673-X","article-title":"Blood management: Transfusion medicine comes of age","volume":"381","author":"Goodnough","year":"2013","journal-title":"Lancet"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1097\/NAN.0000000000000261","article-title":"Is this a blood transfusion reaction? don\u2019t hesitate; check it out","volume":"41","author":"DeLisle","year":"2018","journal-title":"J. Infus. Nurs."},{"key":"ref_27","first-page":"832","article-title":"Acute transfusion reactions encountered in patients at a tertiary care center","volume":"60","author":"Khalid","year":"2010","journal-title":"J. Pak. Med. Assoc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1111\/bjh.12150","article-title":"Current understanding of allergic transfusion reactions: Incidence, pathogenesis, laboratory tests, prevention and treatment","volume":"160","author":"Hirayama","year":"2013","journal-title":"Br. J. Haematol."},{"key":"ref_29","unstructured":"Rossi, E.C., Simon, T.L., Moss, G.S., and Gould, S.A. (1996). Principles of Transfusion Medicine, Williams &Wilkins."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Shaz, B.H., and Hillyer, C.D. (2013). Allergic Transfusion Reactions, Transfusion Medicine and Hemostasis: Clinical and Laboratory Aspects.","DOI":"10.1016\/B978-0-12-397164-7.00048-3"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e29842","DOI":"10.1002\/pbc.29842","article-title":"Comparison of transfusion reactions in children and adults: A systematic review and meta-analysis","volume":"69","author":"Wang","year":"2022","journal-title":"Pediatr. Blood Cancer"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"716184","DOI":"10.3389\/fbioe.2021.716184","article-title":"Platelets in Wound Healing: What Happens in Space?","volume":"9","author":"Locatelli","year":"2021","journal-title":"Front. Bioeng. Biotechnol."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Yamauchi, K., and Ogasawara, M. (2019). The Role of Histamine in the Pathophysiology of Asthma and the Clinical Efficacy of Antihistamines in Asthma Therapy. Int. J. Mol. Sci., 20.","DOI":"10.3390\/ijms20071733"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1164\/rccm.201208-1440OC","article-title":"Production of serotonin by tryptophan hydroxylase 1 and release via platelets contribute to allergic airway inflammation","volume":"187","author":"Duerschmied","year":"2013","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1139\/cjpp-2014-0364","article-title":"Revisiting the Usefulness of Thromboxane-A2 Modulation in the Treatment of Bronchoconstriction in Asthma","volume":"93","author":"Hernandez","year":"2015","journal-title":"Can. J. Physiol. Pharmacol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1177\/0394632015600598","article-title":"Platelet Activating Factor in Allergies","volume":"28","author":"Palgan","year":"2015","journal-title":"Int. J. Immunopathol. Pharmacol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1038\/nm1617","article-title":"Extracellular ATP triggers and maintains asthmatic airway inflammation by activating dendritic cells","volume":"13","author":"Idzko","year":"2007","journal-title":"Nat. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1395","DOI":"10.1016\/j.jaci.2016.01.032","article-title":"Platelets constitutively express IL-33 protein and modulate eosinophilic airway inflammation","volume":"138","author":"Takeda","year":"2016","journal-title":"J. Allergy Clin. Immunol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"846055","DOI":"10.3389\/fimmu.2022.846055","article-title":"Emerging Roles of Platelets in Allergic Asthma","volume":"13","author":"Yue","year":"2022","journal-title":"Front. Immunol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Luo, L., Zhang, J., Lee, J., and Tao, A. (2021). Platelets, Not an Insignificant Player in Development of Allergic Asthma. Cells, 10.","DOI":"10.3390\/cells10082038"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1159\/000151350","article-title":"Reactions induced by platelet transfusions","volume":"35","author":"Kiefel","year":"2008","journal-title":"Transfus. Med. Hemother."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e27724","DOI":"10.1097\/MD.0000000000027724","article-title":"Successful management of severe allergic reactions to platelet transfusion with omalizumab: A case report","volume":"100","author":"Choi","year":"2021","journal-title":"Medicine"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/S0887-7963(05)80026-4","article-title":"IgA anaphylactic transfusion reactions","volume":"9","author":"Sandler","year":"1995","journal-title":"Transfus. Med. Rev."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"766","DOI":"10.1046\/j.1537-2995.2002.00117.x","article-title":"Anaphylactic transfusion reactions in haptoglobin-deficient patients with IgE and IgG haptoglobin antibodies","volume":"42","author":"Shimada","year":"2002","journal-title":"Transfusion"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e934190","DOI":"10.12659\/AJCR.934190","article-title":"A Case of Kounis Syndrome Presenting as Coronary Artery Spasm Associated with Acetaminophen Infusion","volume":"22","author":"Vu","year":"2021","journal-title":"Am. J. Case Rep."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1016\/j.toxicon.2022.09.006","article-title":"Kounis syndrome following an anaphylactic reaction to antivenom in a patient with Russell\u2019s viper (Daboia russelii) bite: A case report","volume":"218","author":"Wedasingha","year":"2022","journal-title":"Toxicon"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"75","DOI":"10.18176\/jiaci.0723","article-title":"Kounis Syndrome in a Covid-19 Patient Following Intravenous Administration of Azithromycin","volume":"32","author":"Gogos","year":"2021","journal-title":"J. Investig. Allergol. Clin. Immunol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e180","DOI":"10.1016\/j.hlc.2015.04.183","article-title":"An Extraordinary Case Associated with an Allergic Reaction to Clopidogrel: Coronary Artery Spasm or Kounis Syndrome?","volume":"24","author":"Liping","year":"2015","journal-title":"Heart Lung. Circ."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.ejro.2019.02.004","article-title":"Kounis syndrome induced by contrast media: A case report and review of literature","volume":"6","author":"Shibuya","year":"2019","journal-title":"Eur. J. Radiol. Open"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e245047","DOI":"10.1136\/bcr-2021-245047","article-title":"Iodinated contrast media induced Kounis syndrome during coronary angiogram: A life-threatening clinical dilemma","volume":"15","author":"Bonnet","year":"2022","journal-title":"BMJ Case Rep."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1080\/08998280.2019.1581319","article-title":"Kounis syndrome secondary to gadolinium contrast agent","volume":"32","author":"Abusnina","year":"2019","journal-title":"Baylor Univ. Med. Cent. Proc."},{"key":"ref_52","first-page":"6087176","article-title":"Kounis Syndrome Secondary to Laxative Administration","volume":"2022","author":"Ardila","year":"2022","journal-title":"Case Rep. Med."},{"key":"ref_53","first-page":"5185716","article-title":"Cardiogenic Shock due to Kounis Syndrome following Cobra Bite","volume":"2019","author":"Priyankara","year":"2019","journal-title":"Case Rep. Crit. Care"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.tjem.2017.12.005","article-title":"Kounis syndrome due to hirudotherapy (leech therapy) in emergency department; a case report","volume":"18","author":"Savrun","year":"2018","journal-title":"Turk. J. Emerg. Med."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"675","DOI":"10.29271\/jcpsp.2020.06.675","article-title":"A Dangerous Octopus Fishing: Kounis Syndrome Following an Octopus Bite","volume":"30","author":"Scagliola","year":"2020","journal-title":"J. Coll. Physicians Surg. Pak."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1186\/s12948-020-00121-w","article-title":"Near-fatal anaphylaxis with Kounis syndrome caused by Argas reflexus bite: A case report","volume":"18","author":"Boni","year":"2020","journal-title":"Clin. Mol. Allergy"},{"key":"ref_57","first-page":"e26395","article-title":"Kounis Syndrome: An Allergic Acute Coronary Syndrome Due to a Bee Sting","volume":"14","author":"Thwe","year":"2022","journal-title":"Cureus"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"328","DOI":"10.5543\/tkda.2021.08834","article-title":"Acute coronary syndrome because of a scorpion sting in a patient with chronic coronary syndrome: A case report and review of the literature","volume":"49","year":"2021","journal-title":"Turk. Kardiyol. Dern. Ars."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"301","DOI":"10.11604\/pamj.2018.30.301.14948","article-title":"Kounis syndrome induced by oral intake of aspirin: Case report and literature review","volume":"30","author":"Hangouche","year":"2018","journal-title":"Pan Afr. Med. J."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1080\/17843286.2018.1535927","article-title":"Allergic myocardial infarction: Type I Kounis syndrome following blue crab consumption","volume":"74","author":"Dogan","year":"2019","journal-title":"Acta Clin. Belg."},{"key":"ref_61","first-page":"134","article-title":"Anaphylactic cardiovascular collapse manifesting as myocardial infarction following salad consumption. A case of Kounis variant type I syndrome","volume":"91","author":"Vaina","year":"2020","journal-title":"Acta Biomed."},{"key":"ref_62","first-page":"e514","article-title":"Vasoespasmo coronario en un ni\u00f1o al\u00e9rgico al l\u00e1tex: S\u00edndrome de Kounis (Coronary vasospasm in a child allergic to latex: Kounis syndrome)","volume":"117","year":"2019","journal-title":"Arch. Argent. Pediatr."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"bcr2012007581","DOI":"10.1136\/bcr-2012-007581","article-title":"Intraoperative myocardial infarction: Kounis syndrome provoked by latex allergy","volume":"2013","author":"Marcoux","year":"2013","journal-title":"BMJ Case Rep."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1016\/j.jaip.2018.05.030","article-title":"Kounis syndrome caused by anaphylaxis without skin manifestations after cefazolin administration","volume":"7","author":"Adachi","year":"2019","journal-title":"J. Allergy Clin. Immunol. Pract."}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/11\/2\/220\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:10:37Z","timestamp":1760119837000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/11\/2\/220"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1,19]]},"references-count":64,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2023,2]]}},"alternative-id":["vaccines11020220"],"URL":"https:\/\/doi.org\/10.3390\/vaccines11020220","relation":{},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,1,19]]}}}