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Cardiovascular syphilis
- 1. Cardiovascular Syphilis Dr Sweta Subhadarshani Junior Resident Dermatology & Venereology AIIMS, New Delhi
- 2. Outline • Epidemiology • Clinical Features • Investigations • Treatment • Prognosis • Follow up
- 4. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up • Early 20th century: 5-10% of death due to cardiovascular disease • Treatment with penicillin since 1940: sharp decline in incidence and mortality • Rarity in recent times: published as case reports • Re-emergence of syphilis in south east Asia and sub-saharan Africa: delayed complications may arise • Still a major cause of ascending aortic aneurysm
- 5. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up • Incidence: 10% in late untreated syphilis • May be higher: If all diagnosis made at autopsy were accepted • Variable criteria by pathologists: mainly chronic inflammation • Male> Females • Concomitant neurosyphilis: 40%
- 6. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up • Onset: 10-40 years from infection • May be earlier in negroes • Many patients give no history of primary/secondary syphilis
- 7. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the heart Syphilis of the great vessels Syphilis of medium sized vessels
- 8. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the heart • Very rare • Diffuse myocarditis • Gummata: • Interventricular septum: bundle branch block • Myocardium • Valves • Origin of pulmonary artery • Pericardium
- 9. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels • Aorta, Pulmonary arteries, great vessels arising from aorta • Syphilis of aorta: most common • Blood borne disssemination in early stage- treponemes reach vasa vasorum-endarteritis obliterans • Aorta is rich in lymphatics: favoured
- 10. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels Aortic involvement: • Uncomplicated aortitis • Coronary ostial stenosis • Aortic regurgitation • Aortic aneurysms
- 11. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels Aortic aneurysms (saccular or fusiform)
- 12. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels Ascending aorta: aneurysm of signs • M/C site of aneurysm due to syphilis • Parasternal dullness on percussion • Arterial pulsation on 2nd and 3rd right spaces • Loud aortic systolic murmur, systolic thrill and loud S2 • Pessure effect: chest pain/ SVC compression • Rupture: sudden death
- 13. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels Arch of aorta: aneurysm of symptoms • Pulsating mass in suprasternal notch • May press on trachea: stridor/brassy cough • Left RLN: hoarseness • Tracheal tug • Cervical sympathetic chain: Horner syndrome • SVC compression • Subclavian steal syndrome • Erosion of T4-T5 • Pressure on nerve roots • Death: rupture into any of mediastinal structures
- 14. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels Descending aorta: aneurysm of no signs and no symptoms • May cause continous back pain • Rarely ruptures
- 15. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of the great vessels OTHER SITES: Abdominal Aorta Innominate artery Left CCA Left SCA
- 16. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Syphilis of medium sized arteries • The cerebral and spinal arteries are sometimes affected • Others are rare: carotid, hepatic, mesenteric, renal, iliac or femoral • Thrombosis/ Aneurysm
- 17. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Serology • Reagin test positive: 90% • Specific tests positive: 100% • Testing for other STI • CSF Evaluation
- 24. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up MMWR / June 5, 2015 / Vol. 64 / No. 3 • Cardiovascular Syphilis with normal CSF examination: • Benzathine Penicillin 2.4 MU x 3 doses at 1 week interval • Treatment paradox: may worsen disease • Surgical management • Treatment of partners
- 25. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up MMWR / June 5, 2015 / Vol. 64 / No. 3 Abnormal CSF examination:
- 26. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up The 2 year mortality rate of untreated syphilitic aneurysm is 80%
- 27. Epidemiology Clinical Features Investigations Treatment Prognosis Follow up Clinical and serological follow up: 6 mo and 12 mo post treatment Oxford Textbook of Medicine: Cardiovascular disorders
- 28. THANK YOU
Editor's Notes
- Cardiomegaly, ascending aorta dilatataion
- 50-year-old man presented with a 1-month history of backache. The clinical examination was remarkable for tenderness in the thoracic spine, early diastolic murmur in the aortic area, and loud aortic component of second heart sound. Chest radiography showed mediastinal widening (arrows) suggestive of an aneurysm of the descending thoracic aorta (A). Two-dimensional transthoracic echocardiography (B, Online Video 1) and aortic root angiography (C, Online Video 2) revealed moderate aortic regurgitation with a dilated ascending aorta. Coronary angiography showed critical stenosis (arrow) of the ostial left main coronary artery (D, Online Video 3). Computed tomography confirmed an aneurysm of the descending thoracic aorta, which was filled with thrombus and eroding D3 to D7 vertebral bodies (E and F). These features were suggestive of syphilitic cardiovascular disease and confirmed with diagnostic titers on a Treponema pallidum hemagglutination assay. The patient was treated with benzathine penicillin and referred for early aneurysm repair, Bentall procedure, and coronary artery bypass surgery, followed by spine stabilization.
- 50-year-old man presented with a 1-month history of backache. The clinical examination was remarkable for tenderness in the thoracic spine, early diastolic murmur in the aortic area, and loud aortic component of second heart sound. Chest radiography showed mediastinal widening (arrows) suggestive of an aneurysm of the descending thoracic aorta (A). Two-dimensional transthoracic echocardiography (B, Online Video 1) and aortic root angiography (C, Online Video 2) revealed moderate aortic regurgitation with a dilated ascending aorta. Coronary angiography showed critical stenosis (arrow) of the ostial left main coronary artery (D, Online Video 3). Computed tomography confirmed an aneurysm of the descending thoracic aorta, which was filled with thrombus and eroding D3 to D7 vertebral bodies (E and F). These features were suggestive of syphilitic cardiovascular disease and confirmed with diagnostic titers on a Treponema pallidum hemagglutination assay. The patient was treated with benzathine penicillin and referred for early aneurysm repair, Bentall procedure, and coronary artery bypass surgery, followed by spine stabilization.