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While rates of syphilis remain high and are rising in many parts of the US, cardiovascular manifestations are rarely reported. We present a case of an HIV-infected patient presenting 10 years after initial syphilis diagnosis and treatment with aortic valve dysfunction and an aortic aneurysm. The case highlights the need for awareness of cardiovascular manifestations of syphilis and their potential severity.
Case Description:
A 47 year old male with well controlled HIV (CD4 498 cells/mm3, viral load undetectable on antiretroviral therapy) was initially evaluated for HIV infection and secondary syphilis with rapid plasma regain (RPR) titer 1:512 in 2005. His RPR titer decreased appropriately after treatment with 2.4 million units benzathine penicillin, and currently is 1:1. Treponema pallidum particle agglutination (TP-PA) is reactive. Routine physical examination in 2015 revealed a new early diastolic decrescendo murmur, and an electrocardiogram revealed no abnormalities. An echocardiogram revealed moderate to severe aortic regurgitation and subsequent CT angiogram showed a 6.8 cm fusiform aneurysm of the proximal ascending aorta. A bioprosthetic aortic valve replacement and ascending hemiarch replacement with graft was performed and pathology revealed lack of intraluminal atherosclerotic plaque formation but adventitial inflammation with plasma cells, gumma-like amorphous areas surrounded by histiocytes and giant cells with calcified plaques. Treponemal PCR and immunohistochemistry on the tissue and additional serologic tests are pending.
Discussion:
The clinical presentation and pathology findings support the diagnosis of cardiovascular syphilis. This case illustrates the need to consider cardiac manifestations of syphilis in patients with a history of syphilis, even decades after treatment. It also emphasizes the fact that cardiovascular syphilis can be asymptomatic; the physical exam remains an essential tool to detect this potentially fatal complication.