Introduction. Nowadays, aortic aneurysm is a rare complication of syphilis, what makes the diagnostic assumption difficult. In the antibiotic era, the incidence of late manifestations of syphilis has dramatically declined. Before the discovery of penicillin, tertiary syphilis was the most common cause of thoracic aortic aneurysm, resulting in 5?10% of cardiovascular deaths¹. Case report. A 62-year-old woman presented to the emergency with a history of chest pain with dorsal irradiation that began a week before, followed by episodes of lesser intensity. Past medical history included hypertension, diabetes, smoking and obesity. Physical examination showed no significant abnormalities. ECG evidenced signs of atrial and ventricular overload and no signs of ischemia. Laboratory evaluation revealed leukocytosis without bandemia (14,700cells/mm3), troponin within normal limits, C-reactive-protein 275mg/L and erythrocyte sedimentation rate 113mm. The chest X-ray showed an increased cardiac area. A chest CT identified a Stanford type A aortic dissection extending to the level proximal to the brachiocephalic trunk. The aorta was dilated (maximum transverse diameter of 6.6 cm) and two regions of intimal rupture, both in the distal ascending aorta, were identified. The patient was kept on continuous monitoring in the ICU, aiming to achieve a strict control of blood pressure and heart rate. Syphilis serology was requested, despite the low probability of syphilitic aortitis, revealing negative VDRL and positive FTA-ABS. The patient denied a previous diagnosis or treatment of syphilis. Echocardiogram showed mildly increased left atrial volume (41mL/m2; reference: ?34mL/m2), normal left ventricular diameters, concentric hypertrophy (septum/posterior wall diastolic thickness 13/11mm) and a borderline global systolic function (ejection fraction 53%), without segmental variation. In addition, it also displayed mild aortic regurgitation, ascending aorta dilatation above the sinotubular junction (41mm), and mild to moderate anterior pericardial effusion (10mm thick) without signs suggestive of increased intrapericardial pressure. Aortic aneurysmectomy and tube graft interposition was performed. Cinecoronariography carried out before surgery revealed no significant coronary stenosis. Surprisingly, anatomopathological examination of the resected aorta showed acute and chronic inflammation of the artery wall, with necrotic foci and degeneration of the middle layer, typical of syphilitic arteritis. The patient had a good postoperative evolution. Treatment for tertiary syphilis was prescribed with benzathine penicillin G 2.4 million units once weekly for three weeks. Lumbar puncture before treatment showed no central nervous system involvement. Conclusions. Despite the extremely low prevalence in patients with aortic aneurysm, syphilitic aortitis should always be borne in mind in clinical practice, since this diagnosis have practical implications for the treatment.
Autores: GUILHERME DAGOSTIN DE CARVALHO, Fernando Pivatto Júnior, Bruno Schaaf Finkler, Márcio Neumann, Felipe Soares Torres, Pedro Guilherme Schaefer, Eduardo Sprinz