Kounis syndrome is defined as the concurrence of acute coronary syndromes including coronary spasm, acute myocardial infarction, and stent thrombosis, together with conditions associated with mast cell and platelet activation, involving interrelated and interacting inflammatory cells. Mast cells influence the inflammatory process decisively, though they are numerically inferior in this inflammatory cascade. Accumulation of eosinophils and mast cells in the splenic red pulp is frequently observed in anaphylactic deaths and can be considered a reliable finding for the postmortem diagnosis of this condition. Moreover, a high concentration of mast cell tryptase in serum and increased numbers of eosinophils and mast cells in the spleen make the diagnosis of anaphylactic death almost conclusive. Increased mast cell tryptase levels in postmortem serum, individually considered, do not allow the diagnosis of anaphylaxis-related death to be reached. On the other hand, neither does identification of mast cells and eosinophils within the coronary artery wall and the myocardium, individually considered, allow the hypothesis of anaphylaxis-related death to be formulated.