J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 3 1 e3 3 3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Images in Cardiovascular CT
Bilateral coronary ostial stenosis secondary to syphilitic aortitis Zhaoping Cheng MDa, Shihua Zhao MDb, Wanli Bi MDa,*, Ximing Wang MDa,* a
Department of Radiology, Shandong Medical Imaging Research Institute, Shandong University, Jingwu Road No 324, Jinan 250021, China b Department of Radiology, Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
article info
abstract
Article history:
Cardiovascular syphilis is associated with the tertiary stage of syphilis infection; it involves
Received 29 April 2014
the ascending aorta and can cause aortic aneurysm, aortic regurgitation, and coronary
Received in revised form
ostial stenosis. We report here a case in which bilateral coronary ostial stenosis and aortic
30 May 2014
regurgitation due to syphilitic aortitis was diagnosed; coronary artery bypass graft was
Accepted 8 June 2014
then performed. ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.
Keywords: Syphilitic aortitis Coronary ostial stenosis Aortic regurgitation Dual-source CT angiography
A 37-year-old man was referred to our hospital with 1-year history of unstable angina. He had no risk factors for atherosclerotic coronary artery disease. The treadmill test was positive for myocardial ischemia. Transthoracic echocardiogram showed severe ostial stenosis of both the left coronary artery and the right coronary artery (Fig. 1). Simultaneously, echocardiogram indicated slight aortic regurgitation and hypokinesia of both mid and basal segments of the posterior and anteroseptal wall. Cardiac CT confirmed high-grade ostial stenosis of both the left main coronary artery and the right coronary artery (Fig. 2AeB). No lesions were observed in the
distal coronary artery. CT clearly showed coronary ostial circumferential aortic wall thickening with partial calcification and thickened wall of the left subclavian artery (Fig. 2CeD). On laboratory findings, rapid plasma reagin card test, Treponema pallidum hemagglutination test, and fluorescent treponemal antibody-absorption test were 16-, 80-, and 1280fold, respectively. After 2 weeks of penicillin treatment, coronary artery bypass grafts were performed. The patient was discharged 2 weeks after the surgery. Antibiotic therapy with penicillin was prescribed for 2 weeks. On postoperative follow-up examination, the patient’s condition was stable.
Conflicts of interest: Zhaoping Cheng is supported by a grant from China Postdoctoral Science Foundation (2014M550658). The other authors declare that there are no conflicts of interest. * Corresponding authors. E-mail addresses: [email protected] (X. Wang), [email protected] (W. Bi). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2014.06.007
332
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 3 1 e3 3 3
Fig. 1 e Parasternal short-axis view transthoracic echocardiography image (A) and color Doppler image with high flow velocities (B) revealed right coronary artery (RCA) ostial severe stenosis (long arrows).
Although syphilitic aortitis has declined because of the efficacy of antibiotic therapy and public health awareness for early syphilis, cases of cardiovascular syphilis are still present. Cardiovascular syphilis is associated with the tertiary stage of syphilis infection, and it usually occurs 10 to 20 years after the initial infection.1 Initial histologic changes include perivascular plasma cell and lymphocytic infiltrates of the aortic
adventitia, which eventually give rise to an obliterative endarteritis, adventitial scarring, and medial necrosis with the destruction of elastic fibers.2 The prevalence of coronary ostial lesions with aortic regurgitation has been reported to be 14% in patients with syphilitic aortitis.3,4 Unlike atherosclerosis, syphilitic coronary ostial stenosis is caused by aortic wall thickening, and coronary lesions distal to the ostia occur only rarely.
Fig. 2 e Preoperation dual-source CT angiography. Axial image (A) confirmed critical obstruction from both right and left main coronary ostia (short black arrows). Three-dimensional volume rendering image (B) demonstrated marked stenosis of the bilateral coronary ostiums (short white arrows). Oblique coronal image (C) revealed circumferential aortic wall thickening (0.48 mm; hollow arrows). Oblique sagittal image (D) revealed thickened wall at the beginning of the left subclavian artery (LSA, long black arrow). AA, ascending aorta; LCA, left coronary artery; RCA, right coronary artery.
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 3 1 e3 3 3
references
1. Feier H, Cioata D, Teodorescu-Branzeu D, Gaspar M. Coronary ostial stenosis in a young patient. Circulation. 2012;125:e367e e368.
333
2. Heggtveit HA. Syphilitic aortitis. A clinicopathologic autopsy study of 100 cases, 1950 to 1960. Circulation. 1964;29:346e355. 3. Jackman Jr JD, Radolf JD. Cardiovascular syphilis. Am J Med. 1989;87:425e433. 4. Machado MN, Trindade PF, Miranda RC, Maia LN. Bilateral ostial coronary lesion in cardiovascular syphilis: case report. Rev Bras Cir Cardiovasc. 2008;23:129e131.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Images in Cardiovascular CT
Bilateral coronary ostial stenosis secondary to syphilitic aortitis Zhaoping Cheng MDa, Shihua Zhao MDb, Wanli Bi MDa,*, Ximing Wang MDa,* a
Department of Radiology, Shandong Medical Imaging Research Institute, Shandong University, Jingwu Road No 324, Jinan 250021, China b Department of Radiology, Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
article info
abstract
Article history:
Cardiovascular syphilis is associated with the tertiary stage of syphilis infection; it involves
Received 29 April 2014
the ascending aorta and can cause aortic aneurysm, aortic regurgitation, and coronary
Received in revised form
ostial stenosis. We report here a case in which bilateral coronary ostial stenosis and aortic
30 May 2014
regurgitation due to syphilitic aortitis was diagnosed; coronary artery bypass graft was
Accepted 8 June 2014
then performed. ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.
Keywords: Syphilitic aortitis Coronary ostial stenosis Aortic regurgitation Dual-source CT angiography
A 37-year-old man was referred to our hospital with 1-year history of unstable angina. He had no risk factors for atherosclerotic coronary artery disease. The treadmill test was positive for myocardial ischemia. Transthoracic echocardiogram showed severe ostial stenosis of both the left coronary artery and the right coronary artery (Fig. 1). Simultaneously, echocardiogram indicated slight aortic regurgitation and hypokinesia of both mid and basal segments of the posterior and anteroseptal wall. Cardiac CT confirmed high-grade ostial stenosis of both the left main coronary artery and the right coronary artery (Fig. 2AeB). No lesions were observed in the
distal coronary artery. CT clearly showed coronary ostial circumferential aortic wall thickening with partial calcification and thickened wall of the left subclavian artery (Fig. 2CeD). On laboratory findings, rapid plasma reagin card test, Treponema pallidum hemagglutination test, and fluorescent treponemal antibody-absorption test were 16-, 80-, and 1280fold, respectively. After 2 weeks of penicillin treatment, coronary artery bypass grafts were performed. The patient was discharged 2 weeks after the surgery. Antibiotic therapy with penicillin was prescribed for 2 weeks. On postoperative follow-up examination, the patient’s condition was stable.
Conflicts of interest: Zhaoping Cheng is supported by a grant from China Postdoctoral Science Foundation (2014M550658). The other authors declare that there are no conflicts of interest. * Corresponding authors. E-mail addresses: [email protected] (X. Wang), [email protected] (W. Bi). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2014.06.007
332
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 3 1 e3 3 3
Fig. 1 e Parasternal short-axis view transthoracic echocardiography image (A) and color Doppler image with high flow velocities (B) revealed right coronary artery (RCA) ostial severe stenosis (long arrows).
Although syphilitic aortitis has declined because of the efficacy of antibiotic therapy and public health awareness for early syphilis, cases of cardiovascular syphilis are still present. Cardiovascular syphilis is associated with the tertiary stage of syphilis infection, and it usually occurs 10 to 20 years after the initial infection.1 Initial histologic changes include perivascular plasma cell and lymphocytic infiltrates of the aortic
adventitia, which eventually give rise to an obliterative endarteritis, adventitial scarring, and medial necrosis with the destruction of elastic fibers.2 The prevalence of coronary ostial lesions with aortic regurgitation has been reported to be 14% in patients with syphilitic aortitis.3,4 Unlike atherosclerosis, syphilitic coronary ostial stenosis is caused by aortic wall thickening, and coronary lesions distal to the ostia occur only rarely.
Fig. 2 e Preoperation dual-source CT angiography. Axial image (A) confirmed critical obstruction from both right and left main coronary ostia (short black arrows). Three-dimensional volume rendering image (B) demonstrated marked stenosis of the bilateral coronary ostiums (short white arrows). Oblique coronal image (C) revealed circumferential aortic wall thickening (0.48 mm; hollow arrows). Oblique sagittal image (D) revealed thickened wall at the beginning of the left subclavian artery (LSA, long black arrow). AA, ascending aorta; LCA, left coronary artery; RCA, right coronary artery.
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 3 1 e3 3 3
references
1. Feier H, Cioata D, Teodorescu-Branzeu D, Gaspar M. Coronary ostial stenosis in a young patient. Circulation. 2012;125:e367e e368.
333
2. Heggtveit HA. Syphilitic aortitis. A clinicopathologic autopsy study of 100 cases, 1950 to 1960. Circulation. 1964;29:346e355. 3. Jackman Jr JD, Radolf JD. Cardiovascular syphilis. Am J Med. 1989;87:425e433. 4. Machado MN, Trindade PF, Miranda RC, Maia LN. Bilateral ostial coronary lesion in cardiovascular syphilis: case report. Rev Bras Cir Cardiovasc. 2008;23:129e131.
