Kounis syndrome associated with COVID-19 infection: cause or coincidence?

Background: Histamine fish poisoning, known as scombroid syndrome, is a foodborne disease caused by histamine toxicity that results from eating specific types of spoiled fish. In some cases it can lead to the development of life-threatening anaphylactic reactions. In literature the possibility of correlated coronary involvements is widely recognized and accepted, cases described are rare, but even more rare if combined with the novel human coronavirus disease COVID-19 infection, the fifth documented pandemic since the 1918 flu pandemic. In this report, we describe a case of acute coronary syndrome in infected patient with COVID-19, for the first time. The occurrence of acute coronary events with allergic or hypersensitivity reactions has been described as the Kounis syndrome, but in few cases it has been associated with scombroid syndrome. Case report: A young woman came to our Emergency Department with erythematous lesions, mild itching, nausea, diaphoresis and weakness, after a meal with canned tuna. Her clinical situation worsened and she developed acute coronary syndrome due to vasospasm. After the first negative result for rapid oropharyngeal swab test of SARS-CoV-2RNA, waiting for molecular oropharyngeal swab during her hospitalization, a few days later she was tested positive for SARS-CoV-2 infection. Acute coronary syndrome in patients with scombroid syndrome is rare to find and more rare if associated with COVID-19 infection. This case demonstrated a linkage of histamine fish poisoning with Kounis syndrome and SARS-CoV-2 infection, allowing us to foster the treatment decision-making process. Why should an emergency physician be aware of this? This syndrome can represent a life-threatening, if not promptly and early known. An emergency physician must have this knowledge, to evaluate accurately the anamnesis of affected patients. Only a circumspect anamnesis can lead us to correct diagnosis and change our decision-making process for treatment.