cardiovascular syphilis

Cardiovascular Syphilis

Dr Sweta Subhadarshani

Junior Resident

Dermatology & Venereology

AIIMS, New Delhi

Outline• Epidemiology• Clinical Features• Investigations• Treatment• Prognosis• Follow up

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

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

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%

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

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the heart

Syphilis of the great vessels

Syphilis of medium sized vessels

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

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

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the great vessels

Aortic involvement:

• Uncomplicated aortitis

• Coronary ostial stenosis

• Aortic regurgitation

• Aortic aneurysms

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the great vessels

Aortic aneurysms (saccular or fusiform)

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

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

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

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the great vessels

OTHER SITES:

Abdominal AortaInnominate arteryLeft CCALeft SCA

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

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Serology

• Reagin test positive: 90%

• Specific tests positive: 100%

• Testing for other STI

• CSF Evaluation

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Electrocardiogram

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Chest Radiograph

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Angiography

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Histopathology

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

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow upMMWR / June 5, 2015 / Vol. 64 / No. 3

Abnormal CSF examination:

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

The 2 year mortality rate of untreated syphilitic aneurysm is 80%

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

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