Uncommon cause of complicated myocardial infarction with normal coronary arteries in a Saudi patient

A case of a young Saudi patient with a previous diagnosis of bronchial asthma, nasal polyps, and chronic smoker, presented with atypical chest pain, elevated serum troponin and borderline ischemic electrocardiogram (ECG) changes, with no significant regional wall motion abnormalities at bedside echocardiography is reported. The patient was admitted to the coronary care unit for continuous monitoring as possible acute coronary syndrome, non-ST elevation myocardial infarction (STEMI). One hour after admission, the patient had ventricular fibrillation (VF) cardiac arrest that required three DC shocks and amiodarone bolus before returning of spontaneous circulation, which followed the fourth shock. The resuscitation took 15 minutes of cardiopulmonary resuscitation (CPR). An immediate 12-leads ECG showed significant ST elevation in precordial leads that mandate an urgent coronary angiogram that revealed patent coronary arteries, therefore spasm of normal coronary arteries was postulated as the operative factor. The cardiac magnetic resonance image (MRI) showed a picture of transmural anterior myocardial infarction, which correlates with the follow up echocardiogram reporting hypokinetic anterior wall. A complete history was taken and no use of illicit drugs or alcohol was found. The unusual presentation in such a patient with evidence of extensive anterior STEMI and normal coronary arteries raise the thought of considering uncommon causes. In view of previous medical history and laboratory evidence of eosinophilia, Kounis syndrome was considered dominant in the differential diagnosis.