Syphilitic aneurysm - A case report.

Sir,

Once a relatively common disorder, cardiovascular syphilis is now a rare entity. Despite effective antibiotic therapy and public health measures, cases of cardiovascular syphilis still occur. Aneurysm is the most common form of presentation in these cases.[1-4] We describe a case of cardiovascular syphilis with aneurysm of aorta.

A 50-years-old man with a history of cough, change of voice, breathlessness, and fever since 15 days was admitted to our hospital. Patient had pallor, prominent neck pulsations, right-side tracheal deviation, fullness in left parasternal region, and left vocal cord paralysis. Chest X-ray showed consolidation in left upper lobe. Ultrasonography (USG) of thorax showed cystic lesion with vascularity in left upper chest suggestive of aneurysm. Computed tomography (CT) thorax showed aneurysmal dilatation of descending arch of aorta [Figure 1]. Hemogram revealed total White Blood Cells (WBC) count of 6800 cells /cmm with Erythrocyte sedimentation rate(ESR) 140 mm/at 1 h. Induced sputum smear examination for acid fast bacilli (AFB) was negative and he was HIV seronegative.

Figure 1

CT thorax showed aneurysmal dilatation of descending arch of aorta

With the clinical evidence of aneurysm and investigations, we tried to search the cause for the same. After ruling out atherosclerosis and tuberculosis, rapid plasma reagin test (RPR, Span diagnostics, Surat, India) was performed with serum sample and found to be reactive with a titre of 1:32. Further it was confirmed at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India, using Treponema pallidum particle agglutination (TP-PA) test (SERODIA-TP-PA Fujirebio Inc., Tokyo Japan, Fujirebio Europe, B.V., Netherlands) with the test being positive with a titre of 1:2560.

Thus patient was diagnosed as a case of syphilitic aneurysm and advised benzathine penicillin, 2.4 million units per week for 3 weeks and referred to cardiovascular surgeon for surgical repair. Patient succumbed to the illness before the surgery. Postmortem was not done as family did not inform the death to the hospital.

Cardiovascular syphilis is a late manifestation of the disease usually occurring after 10-30 years of initial infection. It occurs in 11% of untreated syphilitic patients.[3] In our case after ruling out all the possibilities, cardiovascular syphilis was thought of. Screening with RPR along with TP-PA test ruled out false-positive result.

Antibiotic therapy, in the form of penicillin, should be administered, although surgery is a definitive therapy. The prognosis for patients with syphilitic aneurysms is extremely poor. Rupture into various structures and obstructive pneumonia are relatively common causes of death.[5] In our case, patient presented to the hospital in the late stage of the disease, hence succumbed to the illness before the surgery. Thus, outcome of the therapy might be dependent on the stage of the illness.

In conclusion, successful treatment with penicillin early in the disease will prevent the development of tertiary forms. However, the diagnosis may be missed if early symptoms are mild and transient, particularly in women.[4] Health professionals should rule out syphilis when patient presents with dilatation or calcification of aorta.