cardiovascular syphilis
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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
THANK YOU
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