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Current USPSTF guidelines recommend against routine screening of syphilis in low-risk, asymptomatic individuals. However, recent trends have demonstrated increasing rates of syphilitic infections. We describe a case of tertiary syphilis in a man with poor medical follow-up who presents with a thoracic aortic aneurysm with a hemorrhagic aorto-esophageal fistula.
Case Description:
A 58-year-old man with history of tobacco abuse presents with syncope secondary to an episode of large-volume hematemesis. He is found to be severely hypotensive and continues to have persistent hematemesis. Pressor support is initiated and the patient is intubated for airway protection. EGD is performed showing no active bleeding but two gastric ulcers, which are clipped. Despite this, hematemesis does not resolve. A CT chest reveals extensive pneumoperitoneum (likely due to recent EGD manipulation) and a 6cm descending thoracic aortic aneurysm. Given concern for an actively hemorrhaging aorto-esophageal fistula, the patient is transferred to a tertiary care center for surgery. He successfully undergoes repairs of thoracic aortic aneurysm, esophageal tear, and gastric perforation. Pathology returns as giant cell and granulomatous aortitis with necrotizing granulomas. Staining for fungus, bacteria, and AFB are negative. Serologies are normal, except for a positive RPR (titers 1:16) and reactive FTA-ABS. The patient admits to prior contact with sex workers decades ago, but no history of ulcers, rashes, or IVDU. He denies previous STD screening. He is started on Penicillin G and subsequently discharged with follow-up for continued treatment and monitoring.
Discussion:
This near-catastrophic case of tertiary syphilis highlights the importance of preventive STD screening. Cardiovascular syphilis accounts for 10-15% of all cardiovascular disorders and, although a late stage of disease progression, is preventable. A thorough history of risk factors and a lower threshold for screening should be considered in all patients given the potentially life-threatening complications of this infection.