Bee sting–associated Kounis syndrome with acute aortoiliac occlusion and bilateral lower limb ischemia: a fatal case report

Hymenoptera stings can trigger anaphylaxis and, in susceptible patients, allergic acute coronary syndrome, known as Kounis syndrome. Although coronary involvement is the best-recognized vascular manifestation, severe anaphylaxis may occasionally be accompanied by major non-coronary arterial events. Acute aortoiliac occlusion in this setting is rarely described and poses an immediate threat to limb viability. A 61-year-old man with type 2 diabetes mellitus, hypertension, active smoking, and known coronary artery disease was referred to our center with anaphylactic shock after multiple bee stings. On arrival, he had severe bilateral ischemic rest pain, absent femoral pulses, cold and pale lower limbs, absent femoral and distal arterial Doppler signals, and bilateral motor weakness of approximately 2–3/5. These findings were consistent with Rutherford IIb bilateral acute lower limb ischemia. Computed tomography angiography showed short-segment occlusion of the distal abdominal aorta and proximal segments of both common iliac arteries, together with irregular atherosclerotic plaque in the proximal abdominal aorta. Initial Fogarty thrombectomy did not restore adequate proximal inflow, and an aortobifemoral bypass was performed using a bifurcated Dacron graft. Postoperatively, troponin I rose markedly, and coronary angiography revealed a severe circumflex artery lesion that was treated with drug-eluting stent implantation. The subsequent intensive care course was complicated by severe lactic/metabolic acidosis, rhabdomyolysis, hyperkalemia, progressive acute kidney injury, escalating vasopressor requirement, and cardiogenic shock. The patient died on the second hospital day. This fatal case illustrates that bee sting–associated anaphylaxis may be accompanied by both an acute coronary event compatible with type II Kounis syndrome and acute aortoiliac occlusion causing bilateral limb-threatening ischemia. In patients with severe anaphylaxis, particularly those with atherosclerotic risk factors, early peripheral vascular assessment and a low threshold for vascular imaging may be warranted when limb ischemia is suspected.