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Cardiovascular Syphilis Dr Sweta Subhadarshani Junior Resident Dermatology & Venereology AIIMS, New Delhi

Cardiovascular syphilis

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Page 1: Cardiovascular syphilis

Cardiovascular Syphilis

Dr Sweta Subhadarshani

Junior Resident

Dermatology & Venereology

AIIMS, New Delhi

Page 2: Cardiovascular syphilis

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

Page 3: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Page 4: Cardiovascular syphilis

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

Page 5: Cardiovascular syphilis

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%

Page 6: Cardiovascular syphilis

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

Page 7: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the heart

Syphilis of the great vessels

Syphilis of medium sized vessels

Page 8: Cardiovascular syphilis

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

Page 9: Cardiovascular syphilis

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

Page 10: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the great vessels

Aortic involvement:

• Uncomplicated aortitis

• Coronary ostial stenosis

• Aortic regurgitation

• Aortic aneurysms

Page 11: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the great vessels

Aortic aneurysms (saccular or fusiform)

Page 12: Cardiovascular syphilis

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

Page 13: Cardiovascular syphilis

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

Page 14: Cardiovascular syphilis

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

Page 15: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Syphilis of the great vessels

OTHER SITES:

Abdominal AortaInnominate arteryLeft CCALeft SCA

Page 16: Cardiovascular syphilis

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

Page 17: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Serology

• Reagin test positive: 90%

• Specific tests positive: 100%

• Testing for other STI

• CSF Evaluation

Page 18: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Electrocardiogram

Page 19: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Chest Radiograph

Page 20: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Angiography

Page 21: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

Histopathology

Page 22: Cardiovascular syphilis
Page 23: Cardiovascular syphilis
Page 24: Cardiovascular syphilis

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

Page 25: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

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

Abnormal CSF examination:

Page 26: Cardiovascular syphilis

Epidemiology

Clinical Features

Investigations

Treatment

Prognosis

Follow up

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

Page 27: Cardiovascular syphilis

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

Page 28: Cardiovascular syphilis

THANK YOU