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Syphilitic Aortitis in Secondary Syphilis FREE

Andreas Dietrich, MD1; Gerd G. Gauglitz, MD1; Thomas T. Pfluger, MD, PhD2; Thomas Herzinger, MD, PhD1; Markus Braun-Falco, MD, PhD1
[+] Author Affiliations
1Department of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
2Department of Nuclear Medicine, Ludwig-Maximilian-University, Munich, Germany
JAMA Dermatol. 2014;150(7):790-791. doi:10.1001/jamadermatol.2013.9537.
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Published online

Syphilis is a mainly sexually transmitted infection that may show a variety of symptoms at various stages. Syphilitic aortitis is a known complication of tertiary syphilis and can cause aneurysm of the aorta.1 In the era of antibiotics, cardiovascular syphilis has become very rare.2 Nevertheless it can cause life-threatening or even fatal symptoms and should therefore be diagnosed at an early stage.3

REPORT OF A CASE

A man in his 70s presented with a 4-week history of an asymptomatic eruption, bilateral lymphadenopathy, and slightly reduced general condition. Physical examination revealed generalized dark purple scaly plaques and nodules (Figure 1) involving soles and palms.

Place holder to copy figure label and caption
Figure 1.
Clinical Image of Secondary Syphilis

Dark purple scaly plaques and nodules on the thighs.

Graphic Jump Location

Routine laboratory tests showed elevated C-reactive protein and liver enzyme levels. Hematoxylin-eosin staining of a tissue specimen demonstrated an inflammatory infiltrate with some plasma cells. Immunohistochemical findings were positive for Treponema pallidum. Serologic results were negative for human immunodeficiency virus and hepatitis. The results for the VDRL (Venereal Disease Research Laboratory test) (1:128), TPPA (Treponema pallidum particle agglutination assay) (1:10240), and FTA-Abs (fluorescent treponemal antibody-absorption) IgG test were positive, and the level of 19S IgM FTA-Abs was marginally elevated, confirming the diagnosis of syphilis. Ocular and neurologic involvement was excluded. A chest radiograph showed an enlarged aortic contour suggestive of dilative aortic angiopathy without any signs of aneurysm. Radiographic computed tomography (CT) demonstrated thickening of the aortic wall and aortic sclerosis in the transverse plane. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) alongside CT (PET/CT) demonstrated a maximum isotope uptake of the descending aorta, confirming the suspected diagnosis of an aortitis (Figure 2). We thus diagnosed secondary syphilis with asymptomatic aortitis. To prevent aortic rupture triggered by massive cell disintegration of T pallidum microorganisms (Herxheimer reaction), we implemented a prophylaxis with 100-mg prednisolone prior to the antibiotic therapy with penicillin G, 6 × 5 Mio IU/d, over a 2-week period.

Place holder to copy figure label and caption
Figure 2.
Syphilitic Aortitis Diagnosis Confirmed Via Multiple Imaging Techniques

A, 18F-Fluorodeoxyglucose (18F-FDG)positron emission tomography (PET) demonstrates a maximum isotope uptake of the descending aorta. B, 18F-FDG PET alongside computed tomography (CT) clearly demonstrates the maximum isotope uptake of the descending aorta. C, Radiographic CT demonstrates thickening of the aortic wall and aortic sclerosis in the transverse plane.

Graphic Jump Location

DISCUSSION

Syphilitic aortitis is a potential serious complication of usually chronic tertiary syphilis.4 It is exceedingly rare in secondary syphilis, as seen in our patient. It often is an incidental radiologic finding, and signs of infection (eg, fever and leukocytosis) are often missing. Performing 18F-FDG–PET/CT scan may allow the early diagnosis of syphilitic aortitis at a subclinical stage and prevent life-threatening or fatal outcome.5,6

ARTICLE INFORMATION

Corresponding Author: Andreas Dietrich, MD, Department of Dermatology and Allergy, Ludwig-Maximilian-University, Frauenlobstr 9-11, 80337 Munich, Germany (andreas.dietrich@med.uni-muenchen.de).

Published Online: March 5, 2014. doi:10.1001/jamadermatol.2013.9537.

Conflict of Interest Disclosures: None reported.

Additional Information: Drs Dietrich and Gauglitz contributed equally to this article.

REFERENCES

Plewig  G, Landthaler  M, Burgdorf  WHC, Hertl  M, Ruzicka  T. Braun-Falco's Dermatologie, Venerologie und Allergologie.6th ed. Berlin, Germany: Springer; 2012.
Paulo  N, Cascarejo  J, Vouga  L.  Syphilitic aneurysm of the ascending aorta. Interact Cardiovasc Thorac Surg. 2012;14(2):223-225.
PubMed   |  Link to Article
Rockwell  DH, Yobs  AR, Moore  MB  Jr.  The Tuskegee Study of Untreated Syphilis; the 30th Year of Observation. Arch Intern Med. 1964;114:792-798.
PubMed   |  Link to Article
Jackman  JD  Jr, Radolf  JD.  Cardiovascular syphilis. Am J Med. 1989;87(4):425-433.
PubMed   |  Link to Article
Balink  H, Spoorenberg  A, Houtman  PM, Brandenburg  A, Verberne  HJ.  Early recognition of aortitis of the aorta ascendens with ¹⁸F-FDG PET/CT: syphilitic? Clin Rheumatol. 2013;32(5):705-709.
PubMed   |  Link to Article
Treglia  G, Taralli  S, Maggi  F, Coli  A, Lauriola  L, Giordano  A.  Usefulness of (18)F-FDG PET/CT in disease extent and treatment response assessment in a patient with syphilitic aortitis. Clin Nucl Med. 2013;38(4):e185-e187.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Clinical Image of Secondary Syphilis

Dark purple scaly plaques and nodules on the thighs.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Syphilitic Aortitis Diagnosis Confirmed Via Multiple Imaging Techniques

A, 18F-Fluorodeoxyglucose (18F-FDG)positron emission tomography (PET) demonstrates a maximum isotope uptake of the descending aorta. B, 18F-FDG PET alongside computed tomography (CT) clearly demonstrates the maximum isotope uptake of the descending aorta. C, Radiographic CT demonstrates thickening of the aortic wall and aortic sclerosis in the transverse plane.

Graphic Jump Location

Tables

References

Plewig  G, Landthaler  M, Burgdorf  WHC, Hertl  M, Ruzicka  T. Braun-Falco's Dermatologie, Venerologie und Allergologie.6th ed. Berlin, Germany: Springer; 2012.
Paulo  N, Cascarejo  J, Vouga  L.  Syphilitic aneurysm of the ascending aorta. Interact Cardiovasc Thorac Surg. 2012;14(2):223-225.
PubMed   |  Link to Article
Rockwell  DH, Yobs  AR, Moore  MB  Jr.  The Tuskegee Study of Untreated Syphilis; the 30th Year of Observation. Arch Intern Med. 1964;114:792-798.
PubMed   |  Link to Article
Jackman  JD  Jr, Radolf  JD.  Cardiovascular syphilis. Am J Med. 1989;87(4):425-433.
PubMed   |  Link to Article
Balink  H, Spoorenberg  A, Houtman  PM, Brandenburg  A, Verberne  HJ.  Early recognition of aortitis of the aorta ascendens with ¹⁸F-FDG PET/CT: syphilitic? Clin Rheumatol. 2013;32(5):705-709.
PubMed   |  Link to Article
Treglia  G, Taralli  S, Maggi  F, Coli  A, Lauriola  L, Giordano  A.  Usefulness of (18)F-FDG PET/CT in disease extent and treatment response assessment in a patient with syphilitic aortitis. Clin Nucl Med. 2013;38(4):e185-e187.
PubMed   |  Link to Article

Correspondence

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