Computed Tomographic and Morphologic Features of Syphilis of the Aorta

Massive Calcification of the Ascending Aorta Secondary to Irradiation for Hodgkin's Disease Decades Earlier in Association with Aortic Valve Stenosis

Described herein are findings in 2 men who developed massively calcified non-dilated ascending aortas decades after receiving mediastinal irradiation for treatment of Hodgkin's disease associated with aortic valve stenosis. The quantity of the intimal aortic calcium was remarkable and much greater than in other aortic conditions. The ascending aorta had to be excised in one patient in order to replace the stenotic aortic valve. The other patient underwent percutaneous transluminal aortic valve implantation.

Combined Cardiovascular Syphilis and Type A Acute Aortic Dissection

The occurrence of acute aortic dissection with the initiating tear in the ascending aorta superimposed on cardiovascular syphilis is an exceedingly rare occurrence. Such was the case, however, in a recently seen patient who presented with typical features of acute dissection (type A). Operative repair yielded the entire ascending aorta to examine both grossly and histologically and classic features of both conditions were observed.

Syphilitic aortitis: still a current common cause of aneurysm of the tubular portion of ascending aorta

Aortic syphilis today is infrequently diagnosed clinically. Described herein are findings in 5 women who had resection of a fusiform aneurysm of the tubular portion of ascending aorta, and examination of the wall of the aneurysm disclosed classic features of aortic syphilis. The 5 patients were among 36 who had ascending aortic operations at Baylor University Medical Center in Dallas in 2018 and early 2019. Syphilitic aneurysm in each spared the sinus portion and involved diffusely the tubular portion of ascending aorta, beginning at the sinotubular junction. The aneurysmal wall was thicker than normal because of thickening of both intima and adventitia. The latter contained foci of lymphocytes and plasmacytes and thickened and narrowed vasa vasora. The media was disrupted by fibrous scars, which weakened the integrity of the aorta. Aortitis of the tubular portion of ascending aorta in syphilis is a diffuse process, but often is mistakenly called "atherosclerosis" which, when present in this portion of aorta, can be extensive but is focal. Aortic syphilis is important to diagnose so that patients can receive antibiotic therapy to delay, prevent, or treat neurosyphilis, a common accompaniment of aortic syphilis.

Operative Recognition of Syphilis of the Aorta

Aortic syphilis has not disappeared. Few patients with aortic syphilis are diagnosed pre-operatively or after histologic examination of the resected aortas. The gross features of the wall of the syphilitic aortic aneurysm, however, are unique allowing diagnosis of this entity on the operating table. Thirty patients aged 33 to 84 years (mean 66) (18 women) had a syphilitic aneurysm involving the tubular portion of ascending aorta resected at Baylor University Medical Center at Dallas from 2009 through 2017. That syphilis was the cause of the aneurysm was not appreciated either preoperatively or at operation. Syphilis produces characteristic changes in the aorta: it is thicker than normal due to fibrous thickening of the intima and adventitia, the intimal surface is 100% abnormal, and the sinus portion of the aorta is uninvolved. The process begins at or just distal to the sinotubular junction. Histologic findings are specific. A negative serologic test for syphilis does not rule out the presence of syphilis of the aorta. The key to identifying at operation syphilis of the aorta is to note that its entire intimal surface is abnormal, that one or more saccular aneurysms may arise from the fusiform aneurysm, that the aneurysmal wall isthicker than normal, and that the wall of the sinus portion of the aorta is spared. Identificationof the syphilitic cause appears to be important because antibiotic therapy is recommended to prevent or retard the development of neurological syphilis, particularly in the younger patients.

Late Cardiovascular Syphilis

A case of belatedly diagnosed late cardiovascular syphilis that had continued progressing despite two courses of ceftriaxone therapy is described. The patient had a combination of all possible complications of syphilitic mesaortitis including aortic regurgitation, coronary insufficiency, as well as fusiform aneurysm of the ascending aorta and the proximal aortic arch. Current issues of diagnosis and therapy of late cardiovascular syphilis are discussed.