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Case Study

A case of syphilitic aortic aneurysm with sternal erosion and impending rupture

Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314556548 aan.sagepub.com

Khadhar Mohamed Sarjun Basha1, Karthik Raman2, Sheriff Ejaz Ahmed2, Kalidoss Latchumanadoss1 and Sethuratnam Rajan2

Abstract Syphilitic aortic aneurysm is a rare occurrence in the current antibiotic era. Cardiovascular syphilis has nearly disappeared in developed countries, although it remains a factor in differential diagnosis in developing nations. We report a case of syphilitic aortic aneurysm eroding through the sternum in a 52-year-old man who underwent successful surgical repair.

Keywords Aortic aneurysm, thoracic, sternum, syphilis, cardiovascular

Introduction Syphilitic aortic aneurysm is a rare occurrence in the current antibiotic era. Cardiovascular syphilis has nearly disappeared in developed countries, although it remains a factor in differential diagnosis in developing nations. Recognition of cardiovascular syphilis is important because in addition to the broader management of aneurysmal disease, it warrants antibiotic therapy for which penicillin is preferred.

Case report A 52-year-old man presented with complaints of pain and a progressively increasing swelling in the upper part of the sternum of one month duration. He had dyspnea in New York Heart Association class II for the previous 15 days. He had been diagnosed with pulmonary tuberculosis 5 years earlier, which was treated with a full course of antitubercular therapy, and he had a history of multiple sexual contacts. Clinical examination revealed a tense swelling measuring 3  4 cm with an expansile pulsation over the upper part of the sternum (Figure 1). A hemogram, biochemistry, coagulation profile, Mantoux and sputum tests for acid-fast bacilli were unremarkable, and viral markers of human immunodeficiency virus 1 and 2 and hepatitis B and C were negative. The Venereal Disease Research

Laboratory test was positive for syphilis with a titre of 1/64 (significant for past infection) and a Treponema pallidum hemagglutination assay gave a titre of 1/200 (significant for active infection). Echocardiography revealed good biventricular function with an aneurysm of the distal ascending aorta. The aortic root diameter and aortic valve were normal. A computed tomography aortogram (Figure 2) confirmed a saccular aneurysm in the ascending aorta, extending proximally 6.3 cm from the aortic valve and distally to the level of the innominate artery origin, measuring 77 mm at its maximum diameter with sternal destruction and soft tissue swelling. Urgent surgical repair of the aneurysm was undertaken. The right axillary artery and femoral vein were cannulated. After establishing cardiopulmonary bypass, a left ventricular apex vent was placed through a separate anterolateral 1 Department of Cardiology, Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, India 2 Department of Cardiothoracic Surgery, Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, India

Corresponding author: Khadhar Mohamed Sarjun Basha, Department of Cardiology, Institute of Cardiovascular Diseases, The Madras Medical Mission, no. 4A JJ Nagar, Mogappair, Chennai, Tamil Nadu 600037, India. Email: [email protected]

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Asian Cardiovascular & Thoracic Annals 0(0)

thoracotomy incision in the left fifth intercostal space. At a core temperature of 18 C (nasopharyngeal), the patient was placed in the Trendelenburg position and the cardiopulmonary bypass flow was reduced to a trickle. The chest was opened through a median sternotomy; partial entry was through the aneurysmal sac itself. An aneurysm eroding through the sternum with thrombotic narrowing of the left subclavian artery and tracheobronchial compression were noted. The sac was opened fully, the clots were removed, and the sac with a 3-cm mouth was excised (Figure 3). A single dose of antegrade del Nido cold blood cardioplegia was given. A bevelled 26-mm Dacron graft was anastomosed distally to the open arch, using 3/0 polypropylene suture. After clamping the graft, full pump flow was resumed and rewarming was started. Proximally, the graft was anastomosed to the ascending aorta above the

sinotubular junction. The crossclamp was released after deairing. On full rewarming, the patient was weaned off cardiopulmonary bypass. Primary chest closure was carried out and the defect in the upper part of the sternum was covered by bilateral pectoral muscle flaps and approximated at the midline. The rest of the wound was closed conventionally. The postoperative period was uneventful. The patient was treated with intramuscular benzathine penicillin and

Figure 1. The pulsatile swelling eroding through the sternum.

Figure 3. The cavity after aneurysm resection.

Figure 2. Computed tomography showing the ascending aortic aneurysm in (a) coronal section and (b) a reconstructed image.

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Basha et al.

3 primary infection, and in 10% of these patients, significant cardiovascular complications will occur, such as aortic aneurysm, aortic regurgitation, and coronary osteal stenosis.2 The rich lymphatic arrangement in the ascending aorta that may predispose to mesoaortitis is believed to be the reason for the greater involvement of this segment.3 A definitive diagnosis of syphilis can be challenging due to the long latency from primary infection to aneurysmal dilation and the inability to culture Treponema pallidum in standard media. In late syphilis, non-treponemal tests such as the Venereal Disease Research Laboratory test and the rapid plasma reagin test are less sensitive (71%–73%) than treponema-specific tests such as the Treponema pallidum hemagglutination assay, micro-hemagglutination test, or fluorescent treponemal antibody adsorption test (94%–96%).4,5 According to Kuramochi and colleagues,5 serologically proved syphilis is necessary to make a diagnosis of syphilitic aortitis; a histologic finding of mesoaortitis by itself is not diagnostic. Large syphilitic thoracic aortic aneurysms may cause symptoms via mass effects on neighboring mediastinal structures or erosion into the chest wall (as in our patient) and thoracic spinal bodies. Computed tomography aortography is the best imaging study to define the size and anatomy of the aneurysm, but echocardiography and coronary angiography are mandatory to exclude aortic regurgitation and coronary artery disease.5 The definitive treatment is surgery, and any aortic regurgitation and coronary artery disease should be treated concomitantly. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Figure 4. Computed tomography aortography was unremarkable at the 3-month follow-up.

Conflict of interest statement None declared.

References discharged in a hemodynamically stable condition. At the 3-month follow-up, computed tomography aortography was unremarkable (Figure 4).

Discussion Cardiovascular syphilis usually manifests in the 4th–5th decades of life, typically 5–10 years after the primary infection. Without surgical treatment, the mortality rate at 1 year can reach 80% due to the high rate of rupture of these aneurysms.1 Syphilitic aortitis is reported in 70%–80% of untreated cases after the

1. Sacks R, Tipple C and Goldmeier D. Syphilitic aorta: exploring the bigger picture. Int J STD AIDS 2010; 21: 608. 2. Cheng TO. Syphilitic aortitis is dying but not dead. Cathet Cardiovasc Interv 2001; 52: 240–241. 3. Chetty R, Batitang S and Nair R. Large artery vasculopathy in HIV-positive patients: another vasculitic enigma. Hum Pathol 2000; 31: 374–379. 4. Roberts WC, Ko JM and Vowels TJ. Natural history of syphilitic aortitis. Am J Cardiol 2009; 104: 1578–1587. 5. Vaideeswar P. Syphilitic aortitis: rearing of the ugly head. Indian J Pathol Microbiol 2010; 53: 624–627.

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A case of syphilitic aortic aneurysm with sternal erosion and impending rupture.

Syphilitic aortic aneurysm is a rare occurrence in the current antibiotic era. Cardiovascular syphilis has nearly disappeared in developed countries, ...
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