Rocuronium-induced coronary vasospasm — “Kounis syndrome”

A 49-year-old male became hypotensive, bradycardic, and suffered myocardial injury during induction of anesthesia with lidocaine, propofol, and rocuronium in the operating room. Coronary arteriography revealed coronary vasospasm in coronary arteries otherwise free of disease. In the ICU, the patient was again administered rocuronium for a procedure with subsequent hypotension, bradycardia, and ST elevation on telemetry that resolved with administration of diphenhydramine and hydrocortisone. An allergic reaction to rocuronium with coronary vasospasm is suspected, suggestive of the Type 1 variant of Kounis syndrome. This is the first report to describe a case of rocuronium-induced Type 1 Kounis syndrome.