ABSTRACT
Introduction: Kounis syndrome is a complex clinical entity at the intersection of acute coronary syndromes and allergic reactions. Case presentation: We report the case of a 55-year-old woman with hypertension, autoimmune thyroiditis, and recurrent allergic complaints who was admitted with ST-elevation myocardial infarction and found to have myocardial infarction with non-obstructive coronary arteries (MINOCA), likely due to coronary vasospasm. During hospitalization, she developed cutaneous symptoms and was subsequently diagnosed with chronic spontaneous urticaria. Retrospectively, the diagnosis of Kounis syndrome type I was established. Conclusions: Reporting cases with subtle or absent allergic manifestations is essential to improve diagnostic accuracy and guide appropriate management, particularly given the potential for recurrence.