Cases

of the Day

GeneraP Louise

Samson,

MD

#{149} Jean

Cbalaoui,

MD

Bruno #{149}

Para4is,

MD

L Figure 1. (a) (b) Collimated num.

Posteroantenior chest radiograph demonstrates lateral view reveals the mass is in the middle

U HISTORY A 48-year-old white man who suffered gressive middorsa! pain for over a year referred to the orthopedics department consultation. Findings from the physical

Index

terms:

RadloGraphics

Aneurysm,

1990;

I From the Department RSNA annual meeting. CRSNA, 1990

508

U

RadioGrapbks

aortic,

10:508-5

561.7342,

Aortitis,

#{149}

mass with compartments

smooth contours. of the mediasti-

amination did not contribute to the diagnosis. Chest radiography and computed tomography (CT) without and with contrast materia! enhancement (Figs 1 , 2) were performed.

56.2077

Syphilis,

#{149}

56.2077

10

ofRadiology, Received and

U

563.7341

prowas for cx-

a mediastinal and posterior

H#{244}tel-Dieu de Montr#{233}al, 3840 Rue accepted October 3, 1989. Address

Samson

et a!

St Urbain, reprint

Montreal, requests

Que, to L.S.

Canada

H2W

1T8.

Volume

From

the

10

1989

Number

3

.-

a. Figure

2.

erosion

(arrowhead)

the mass

(a)

-.-

Unenhanced

CT scan

of the

adjacent

demonstrates vertebral

body.

mass

fication.

had The

ed, considering

smooth aortic

the

contours arch

was

and

no ca!ci-

relatively

age of the patient.

patient had mild right thoracic sco!iosis otherwise a norma! spine and ribs. The CT scan obtained without contrast tenial (Fig mass with cification.

May

1990

(b)

mass

Enhanced

contiguous

CT scan

with

reveals

the aorta and slight

similar

enhancement

of

and the aorta.

U FINDINGS Chest radiographs (Fig 1) revealed a large mass in the left posterior and middle mediastinum at the level of the middle dorsal spine.

The

b. a mediastinal

dilat-

The but ma-

aortic ta.

arch

Pressure

and

the

erosion

proximal of the

descending adjacent

aor-

vertebral

body was also seen. There was minimal ca!cification of the ascending aorta and minima! thickening of the pleura. On the CT scan taken after a bo!us mnjection of contrast material (Fig 2b) , the mass enhanced as much as the aorta. In addition, a large communication between the two structures was evident.

2a) demonstrated a mediastinal soft-tissue attenuation and no calThe mass was contiguous with the

Samson

et a!

U

Ra4ioGrapbks

U

509

the

initial

spirochete

infection.

The

aorta

is

the most common site of involvement, and the disease may manifest itself as uncomplicated syphilitic aortitis, syphilitic aortic aneurysm,

and

syphilitic

aortic regurgitation. About one-third

aortic

valvulitis

of the patients

with

with

car-

diovascular syphilis do not have symptoms, and the diagnosis is made at autopsy. In the

absence eurysm

of aortic may

without pands

regurgitation,

undergo

producing enough

the aortic

significant

symptoms

to erode

adjacent

an-

enlargement unless it cxbone struc-

tune, aswas the case in ourpatient (1,2). Death secondary to rupture of the aneurysm occurs in up to 40% of cases (2). Figure 3. Left anterior oblique aortogram demonstrates fusiform dilatation of the ascending aorta with irregular margins, a large saccular aneunysm of the proximal descending aorta, and aortic valve regurgitation (arrowheads).

DIAGNOSIS: Syphilitic aortitis, lar aneurysm of the descending siform aneurysm of the ascending

with saccuaorta and fuaorta.

U DISCUSSION Aortography was performed in the patient to confirm the suspected diagnosis (Fig 3). Before undergoing surgery to repair the aneurysms, the patient was tested for syphilis, and the results of two tests (Venereal Disease Research Laboratory [VDRL] test and the microhemagglutinatlon assayTreponemapallidum [MHA-TP] test) were positive. A review of the patient’s history revealed that he had undergone a brief (1 -week) treatment with antibiotics for genital syphilis 30 years before. Findings at surgery confirmed the radiologic diagnosis and demonstrated the typical

“tree-bark” ta. The dilatation

The

appearance aortic valve was of the annulus

base

of the saccular

cally clipped and left received an adequate

and

recovered

U

incompetent and was

to

aneurysm in place. regimen

due replaced.

was

surgi-

insufficiency

may be secondary

cending

as occurred

in our

patient.

REFERENCES

U

1

aorta,

to

by syphilis or to dilatawith aneurysm of the as-

.

Braunwald cardiovascular Saunders,

2.

E.

Heart disease: a textbook medicine. Philadelphia:

1984;

1562-1563.

Posniak LW, Terrence CD, Marsan RE. puted tomography of the normal aorta thoracic

of

aneurysms.

Semin

Comand

Roentgenol

1989;

24:7-21. 3

.

Dutoit aortitis:

DF, McCormich a case report.

M, Laker S Mr MedJ

L.

Syphilitic

1985;

67:

778-779.

4.

Cotran RS, Kumar V, Stanley pathologic basis of disease. Saunders,

1989;

RI. Robbins Philadelphia:

580-581.

The patient of antibiotics

lesions

treated

syphilis

lesions

are

RadioGrapbks

aor-

Aortic

direct involvement tion of the annulus

fully.

Cardiovascular

510

of the ascending

As generally known, the most typical location for syphilitic aortic aneurysm is the ascending aorta (36%) of cases, but the aortic arch (34% of cases) and proximal descending aorta (25% of cases) are almost as frequent!y involved (2) . Most of these aneurysms are saccular. Syphilitic aortitis is characterized by periaortic and mesoaortic inflammation, beginning at the level of the vasa vasorum. These vessels become obstructed, resulting in nutritional impairment of the media and degeneration of muscular fibers, which causes wrinkling of the intima and the tree-bark appearance (3,4).

usually

often occur 1 2% of cases) found 10-25 years

(1 0%-

U

Samson

.

et a!

in unThese after

Volume

10

Number

3