Metrics details Kounis syndrome is a hypersensitivity reaction that induces acute coronary artery events nevertheless its pediatric occurrence remains rare and often underdiagnosed This report describes a fatal case of Kounis syndrome triggered by ceftriaxone-lidocaine administration in a child in the context of sepsis and multiple organ dysfunction syndrome A 4-year girl with a history of cyclic vomiting syndrome was admitted to the ICU with severe lethargy and pallor 30 min after the second intramuscular injection of ceftriaxone Her laboratories were pertinent for a metabolic acidosis elevated cardiac markers (troponin I and cardiac-type creatine phosphokinase) the patient’s condition continued to deteriorated which lead to multiple organ dysfunction and eventual death This case highlights the need for heightened clinical awareness of Kounis syndrome in pediatric settings especially in patients with underlying infections This case underscores the fatal potential of undiagnosed Kounis syndrome in the pediatric population and highlights the urgent need for enhanced vigilance and multidisciplinary preparedness we present a fatal case of Kounis syndrome in a child with sepsis A 4-year-old girl was urgently admitted to the ICU of the Regional Children’s Clinical Hospital at 240 a.m which developed 30 min after the second intramuscular injection of ceftriaxone with lidocaine Her parents denied any medical history of respiratory or other infections within 3 weeks before her admission The illness developed acutely and was characterized by fever Due to the patient developing these acute symptoms her parents were referred to the primary health care unit for treatment of a likely bacterial infection Considering the severity of the patient’s condition and the absence of bacteriological test results and antibiotic susceptibility data ceftriaxone was empirically chosen as a broad-spectrum antibiotic for management of her likely bacterial infection The parents denied a history of any significant medical conditions except for cyclic vomiting syndrome which occurred several times over the past year Her family history was pertinent only for type 2 diabetes mellitus The parents denied any known allergies and she was up to date on routine vaccinations for her age Initial hospital admission with suspected infection intestinal disease; starting management with ceftriaxone Development of allergic reaction (30 min after the second dose of ceftriaxone) Transferred to Regional Children’s Hospital ICU Progressive decline in ejection fraction to 15% Progressive deteriorating coagulation parameters The patient was a well-nourished girl with a body weight of 20 kg (+ 1σ) Vital signs included a body temperature of 36.5 °C and saturation (SpO₂) between 96% and 88% The skin was markedly pale and dry and exhibited reduced turgor with perioral cyanosis The child was stuporous (Glasgow Coma Scale score of 12 and a white spot test > 5 s) tachypnenic with a respiratory rate of 24 breaths per minute dullness in the lower lung fields bilaterally She was tachycardic with a heart rate of 138 bpm and on cardiac auscultation she had weak heart sounds Her blood pressure on admission was 140/100 mmHg There was no organomegaly on abdominal exam with the liver palpable 1.5 cm below the costal margin the spleen was not palpable during the physical exam The patient had been anuric for the past 24 h The diarrhea (7–8 times daily) over the last 48 h which coincided with the onset of fever and vomiting Upon admission to the ICU of the Regional Children’s Clinical Hospital and blood samples were collected for microbiological testing these were non-revealing as the results were negative Electrocardiography (ECG) revealed sinus tachycardia with clinically significant ST-segment depression (Fig. 1). The ECG findings with signs of subendocardial myocardial ischemia Echocardiography revealed significant cardiac impairment (Table 3) Moderate mitral and tricuspid valve insufficiency were present but myocardial wall thickness remained normal No coronary artery abnormalities were observed Chest X-ray: bilateral bronchopneumonia and multifocal pneumonia in the right lower lobe Ultrasonography revealed renal parenchyma with markedly increased echogenicity and reduced systolic flow the patient’s condition worsened due to multiple organ dysfunction syndrome the child was placed on mechanical ventilation and induced into a pharmacologic coma (dobutamine 5–20 µg/kg/min A – Fragment of jejunum with edematous mucosa and neutrophilic inflammatory infiltrates Desquamation of the epithelium with a tendency toward erosive changes signs of active crypt epithelial regeneration and occasional crypt abscesses are observed (acute bacterial enteritis) B – Lung tissue with thickened interalveolar septa and mononuclear inflammatory infiltrates with admixture of neutrophils The alveolar epithelium is flattened and damaged; numerous hyaline membranes are observed Occasional alveolar spaces contain exudate Vascular congestion and microthrombosis (pneumonia-associated diffuse alveolar damage) C – Adrenal gland with massive extravasation of erythrocytes (hemorrhage) into the cortical and medullary regions causing disruption of the gland’s histoarchitecture Microloci of coagulative necrosis with loss of cellular borders and karyolysis Microloci of inflammatory reaction zones (Waterhouse-Friderichsen syndrome) D – Renal medulla with mostly preserved histoarchitecture Foci of tubules show necrotic and apoptotic epithelial changes Numerous vessels exhibit signs of stasis and thrombosis with single perivascular inflammatory cells present (focal acute tubular necrosis of renal tubular epithelium The final clinical diagnosis: Bilateral focal necrotizing pneumonia with abscess formation complicated by toxic syndrome and grade III respiratory failure; infectious-toxic shock; sepsis with multiple organ dysfunction syndrome; anaphylactic shock; and Kounis syndrome concurrently a hypersensitivity reaction culminated in acute coronary syndrome resulting in a fatal outcome within less than a day This case highlights the diagnostic challenges of Kounis syndrome in pediatric patients particularly along with severe infectious complications The fatal outcome underscores the importance of considering allergic myocardial involvement in critically ill children with signs of cardiac ischemia following drug administration Increased awareness and early recognition of Kounis syndrome could improve outcomes through timely intervention and tailored therapeutic strategies No datasets were generated or analysed during the current study Douedi S, Odak M, Mararenko A, Ross J, Sealove B, Kounis Syndrome. 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Namık Kemal Tıp Dergisi. 2024;12(4):342–4. https://doi.org/10.4274/nkmj.galenos.2024.70894 Download references Department of Children’s Diseases of Postgraduate Education Ivano-Frankivsk National Medical University VB - acquisition and data analysis; TK - data interpretation All the authors have read and approved the final version of the manuscript This case report was conducted in accordance with the principles outlined in the Declaration of Helsinki and adhered to ethical guidelines Informed consent was obtained from the parents of the patient Written informed consent was obtained from the parents of the patient for publication of this case report and accompanying images The authors declare no competing interests Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Download citation DOI: https://doi.org/10.1186/s12245-025-00886-4 Anyone you share the following link with will be able to read this content: a shareable link is not currently available for this article