Deivam S et al. / International Journal Of Advances In Case Reports, 2015;2(2):64-67.

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INTERNATIONAL JOURNAL OF ADVANCES IN
CASE REPORTS

Journal homepage: www.mcmed.us/journal/ijacr

EXPERIENCE OF SYPHILITIC AORTIC ANEURYSM A CASE
REPORT
Deivam S1*, Guru T. Arun2, Prabhu N3, Balasubramanian N1
Department of Skin and STD1, Radiodiagnosis2 and Microbiology3,
Chennai Medical College Hospital and Research Centre (SRM Group), Tiruchirapalli 621 105, Tamilnadu, India.

Corresponding Author:- S.Deivam

E-mail: leptoprabhu@gmail.com

Article Info ABSTRACT

Received 15/10/2014 Syphilitic aortic aneurysm is a rare occurrence in the antibiotic era, making the diagnose assumption
Revised 27/11/2014 even more infrequent. Nonetheless, this pathology can appear and should be suspected in patients
Accepted 02/12/2014 with aortic aneurysm. We report a case of a 52-year old patient who presents with cardiovascular
syphilis and, in the following study; a large ascending aorta aneurysm is identified. The authors
Key words: discuss the diagnostic challenge, the epidemiologic concerns, surgical indication, treatment and
Ascending aorta subsequent follow-up.
dilatation, Syphilis,
Radiography.

INTRODUCTION
The incidence of late manifestations of syphilis after the primary infection, and in 10% of these patients,
has declined almost to a rare entity since the era of significant cardiovascular complications will occur, such
antibiotics. Before the discovery of penicillin, tertiary as aortic aneurysm, aortic regurgitation and coronary ostia
syphilis infection was the most common cause of thoracic stenosis. The ascending aorta is the segment most
aortic aneurysm, resulting in 510% of cardiovascular commonly affected (50%), followed by the arch (35%) and
deaths. The primary lesion of cardiovascular syphilis is the descending aorta (15%). The rich lymphatic
aortitis, an inflammatory response to the invasion of the arrangement in the ascending aorta that may predispose
aortic wall by the Treponema pallidum that evolves to greater mesoaortitis is believed to be the cause for larger
obliterative endarteritis of the vasa vasorum and results in involvement of this segment [4]. Cardiovascular syphilis is
necrosis of the elastic fibres and connective tissue in the a late form of syphilis, which usually manifests in the 4th
aortic media [1]. Syphlitic aortitis takes place during the 5th decade of life, typically 540 years after the primary
stage of tertiary syphilis between 5 to 30 years after infection [5,6]. It may become symptomatic with thoracic
appearance of primary syphilis. This is normally due to pain or symptoms of compression of the surrounding
infection of aorta secondary to endarteritis obliterans of structures, but can enlarge asymptomatically until
vasa-vasorum. Aortic wall becomes progressively incidental finding in chest X-ray or a catastrophic and
weakened due to chronic inflammation. This will often fatal aneurysmal rupture. Without surgical treatment,
subsequently lead to aneurysm (10%), coronary artery the mortality rate at 1 year can reach 80% due to the high
narrowing at ostium (30%) and aortic valve insufficiency rate of rupture of these aneurysms [5,6].
secondary to the involvement of aortic valve [2,3]. In the natural course of cardiovascular syphilis,
The resulting weakening of the aortic wall will the primary infection is followed by T. pallidum invasion
progress into the late vascular manifestations of syphilis. of the aortic wall, initially within the adventitia and soon
Syphilitic aortitis is reported in 7080% of untreated cases thereafter in the lymphatic vessels. The rich

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lymphatic system of the ascending aorta is one of the main normal examination, except for dilated neck veins and the
reasons for the tropism of spirochetes there. The vasa history of alcoholism, he was provisionally diagnosed as
vasorum then undergoes a process of endarteritis acid peptic disease and treated accordingly. During the
obliterans, necrosis of medial layer (mesoarteritis) and evaluation of dyspnea, a chest x-ray was taken and it
infiltration of plasma cells [7]. Consequently, the elastic showed anterior mediastinal mass.
tissue of the vessel is destroyed and replaced by scar tissue. On further work-up, CECT study of thorax
The inflammatory process may continue for as long as 25 showed large focally dilated contrast opacified ascending
years after the initial infection. The initial clinical aorta with peripherally unenhancing hypodense thrombus
presentation may then be of angina when there is and calcification involving ascending aorta extending to
obstruction of the coronary ostia or dyspnea when there is right side of anterior mediastinum. SVC was compressed
aortic valve incompetence or compression of the suggestive of ascending aorta aneurysm. The non contrast
respiratory organs. However, the most common clinical axial image shows abnormal aneurysmal dilatation of arch
symptom is chest pain secondary to rapid expansion of the of aorta with peripheral calcification and CECT axial
luetic aneurysm [8]. A case report previous reported image showed aneurysmal dilatation of arch of aorta are
describes an abnormally advanced syphilitic aortic depicted in Figure 1 and 2 respectively. Entire lumen size
aneurysm for such a young patient, a condition likely was 11 cms, thrombus thickness is 4 cm, lumen size 6 cms.
exacerbated by his HIV infection [9]. The rupture of this Figure 3 suggested the CECT sagittal image shows
aneurysm resulted in hypovolemic shock and sudden death, aneurysmal dilatation of the aortic root, ascending aorta,
a tragedy, which could have been prevented with existing arch of aorta and descending thoracic aorta where the
treatment, adequate screening, and additional resources. peripherally non-enhancing hypodense thrombus seen.
The authors report a currently rare case of syphilitic Figure 4 suggested CECT axial image shows aneurysmal
ascending aorta aneurysm at tertiary care teaching hospital dilatation of arch and descending aorta with peripherally
in Tiruchirapalli, India. located thrombus.
ECHO suggested Mediastinal mass lymphoma.
Case report The scout image shows left side radio-opacification
A 52 year old male patient admitted with the (Figure 5). Cardiothoracic surgeon opinion was obtained
complaints of vomiting, dyspnea and loss of appetite for 6 and suggested angiogram, fasting lipid profile, renal
months duration. There was no co morbid association. He function test and blood VDRL for further evaluation of
was an alcoholic for about 29 years with almost daily mediastinal compression syndrome. RPR was reactive in
intake of alcohol. On examination, he was conscious and 128 dilutions. TPHA was also found to be reactive. He was
general examinations including vital signs were all normal. diagnosed as a case of syphilitic aortic aneurysm and
Cardiovascular and Respiratory systems were normal. treated with procaine penicillin 8 lakh units for 20 days.
Abdomen was soft on palpation with few dilated veins. The patient was referred to higher centre for further
Tremors of hands were present. With the apparently management.

Fig 1. Non-contrast axial image shows abnormal Fig 2. CECT axial image shows aneurysmal dilatation of
aneurysmal dilatation of arch of aorta with peripheral arch of aorta
calcification

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Fig 3. CECT sagittal image shows aneurysmal dilatation Fig 4. CECT axial image shows aneurysmal dilatation of
of the aortic root, ascending aorta, arch of aorta and arch and descending aorta with peripherally located
descending thoracic aorta thrombus

[Note: Peripherally non-enhancing hypodense thrombus seen]

Fig 5. Scout image shows left side radio-opacification

DISCUSSION uncommon in developing countries. It usually presents in

Syphilis, the great imitator, the disease per se has the 4th to 5th decade of life and is unusual in the elderly.
become a rare occurrence. The reason being said is the Aortic aneurysms and aortic regurgitation due to
wide use of antibiotics for other infections. Cardiovascular aortic root dilatation is the usual presentation.
syphilis is the tertiary stage which occurs 15 to 30 years Nevertheless, it can remain undetected for the duration of
after primary syphilis. The changes are more marked in its latent period which may extend upto 40 years and is
ascending aorta and aortic arch but syphilitic aneurysm often diagnosed on routine evaluation [11].
have been reported in descending aorta also [10]. We Syphilitic aortitis causes focal destruction of the
present the case for its rarity in this era of higher media, with loss of the elastic smooth muscle fibres and
antibiotics usage and also to emphasis the need for scarring. This leads to an aortic dilatation and an
adequate therapy when a case of syphilis is diagnosed aneurysm. The most common sites of these TAAs are the
because inadequate therapy advances complications. We ascending thoracic aorta (36% of the cases), followed by
should always have a high index of suspicion and rule out the aortic arch (34% cases), the proximal descending
cardiovascular syphilis in all the cases of mediastinal mass thoracic aorta (25% cases), and the distal descending
especially in adults of 4th to 5th decade as in our patient he thoracic aorta (5% cases). Aortic sinus involvement occurs
was admitted for alcoholic gastritis and the aneurysm is an in less than 1% of the cases and it is most often asymmetric
incidental finding. [10,11]. In late Syphilis, the non-treponemal tests like the
Tertiary syphilis with cardiovascular VDRL test and the rapid plasma reagin test are less
complications is a rarity in the antibiotic era in developed sensitive (70%-75%) as compared to the treponema
nations although diagnoses of syphilitic aortitis are not specific tests such as TPHA, the micro haemagglutination

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assay and the fluorescent treponemal antibody absorption thickened [12].

test (94%-95%). The location of an aneurysm can provide clue to
The imaging of an aortic aneurysm is best done its cause. In a study on 249 aneurysms of the aorta and its
with CECT of the chest and CT angiography. The MRI and branches, it was found that the involvement of the
MR angiography are slightly superior to CT in the ascending aorta alone was usually associated with
evaluation of an aortic dissection. Morphologically, the annuloaortic ectasia. In contrast, atherosclerosis is a more
syphilitic aneurysms are saccular but about 25% are diffuse process and it rarely involves only the ascending
fusiform. A pencil-thin dystrophic aortic wall calcification aorta [10,11]. We discuss the diagnostic challenge due to
is found in up to 40% of the patients. This is most severe in the unusually long latent period in our patient, the
or is entirely confined to the ascending aorta. The delicate epidemiologic concerns, treatment options and possible
calcification is frequently obscured by the thick, irregular, complications.
coarse calcification of secondary atherosclerosis. In the
cases of arteritis, the wall of the aneurysm is frequently

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