Delayed Kounis syndrome and acute renal failure after wasp sting

A fifty-seven year old gentleman developed hemolysis induced oliguric acute renal failure following multiple wasp stings. Patient was hemodynamically stable on dialytic support. Twelve days later, although the patient was recovering from renal failure, he developed sudden onset of tachyarrythmias and echocardiography demonstrated a Takotsubo type of cardiomyopathy. He was managed with amiodarone and hemodialysis. After two more episodes of deterioration, the patient made full recovery from both the renal and cardiac toxicity. A case of delayed Kounis syndrome associated with Takotsubo cardiomyopathy in the setting of acute renal failure is described. The possible mechanism of such a presentation is discussed.