Cardiovascular syphilis

Cardiovascular

Clinicals - History

Fact Explanation
Cardiovascular symptoms may arise, several years following the genital infection Cardiovascular syphilis is referred to Treponema pallidum infection of the heart and vessels which is a manifestation of tertiary syphilis. Tertiary syphilis occurs after about 3 to 10 years after primary infection. Cardiovascular syphilis can lead to aortitis, aortic aneurysm, coronary stenosis, aortic insufficiency and, rarely, to myocarditis. Cardiovascular syphilis is commonly seen in males than in females, and it accounts for about 10 to 15% of the heart diseases seen in patients more than 50 years of age. Cardiovascular symptoms may arise, several years following the genital infection
Cardiovascular syphilis is referred to Treponema pallidum infection of the heart and vessels which is a manifestation of tertiary syphilis. Tertiary syphilis occurs after about 3 to 10 years after primary infection. Cardiovascular syphilis can lead to aortitis, aortic aneurysm, coronary stenosis, aortic insufficiency and, rarely, to myocarditis. Cardiovascular syphilis is commonly seen in males than in females, and it accounts for about 10 to 15% of the heart diseases seen in patients more than 50 years of age.
Asymptomatic During the early stages of the disease patients can be asymptomatic. Patient may present with symptoms after about two to twenty years after the primary infection. Asymptomatic
During the early stages of the disease patients can be asymptomatic. Patient may present with symptoms after about two to twenty years after the primary infection.
Chest pain Coronary artery stenosis and endarteritis obliterans lead to angina. Patients complain of retrosternal chest pain on exertion which relieved with rest. Chest pain
Coronary artery stenosis and endarteritis obliterans lead to angina. Patients complain of retrosternal chest pain on exertion which relieved with rest.
Sudden death Coronary artery stenosis can result in sudden cardiac death due to diminished myocardial perfusion or due to the development of life threatening arrhythmia (ventricular tachycardia, ventricular fibrillation). Rupture of aortic aneurysm is another possible cause for sudden death. Sudden death
Coronary artery stenosis can result in sudden cardiac death due to diminished myocardial perfusion or due to the development of life threatening arrhythmia (ventricular tachycardia, ventricular fibrillation). Rupture of aortic aneurysm is another possible cause for sudden death.
Symptoms of heart failure Acute heart failure can occur with acute coronary syndrome and congestive heart failure develops due to valvular damage (aortic regurgitation). Patients complain of dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea and reduced exercise tolerance. Presence of congestive heart failure affects the prognosis adversely. Symptoms of heart failure
Acute heart failure can occur with acute coronary syndrome and congestive heart failure develops due to valvular damage (aortic regurgitation). Patients complain of dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea and reduced exercise tolerance. Presence of congestive heart failure affects the prognosis adversely.
Symptoms of aortic aneurysm Inflammation of the aortic wall leads to aortitis which later progresses to obliterative endarteritis of the vasa vasorum. This process causes ischemic necrosis of the elastic fibres and connective tissue in the tunica media of the aorta. All these changes weaken the aortic wall leading to dilatation and aneurysm formation.
Aortic aneurysm is a late complication of the cardiovascular syphilis. The classic triad of ruptured aortic aneurysm is abdominal or back pain, hypovolaemic shock, and a pulsatile abdominal mass. Other complaints include pulsatile anterior chest wall mass, palpitations, dyspnea, chest pain which radiates to back, dysphagia, cough, and hemoptysis (due to tracheal compression).
Symptoms of aortic aneurysm
Inflammation of the aortic wall leads to aortitis which later progresses to obliterative endarteritis of the vasa vasorum. This process causes ischemic necrosis of the elastic fibres and connective tissue in the tunica media of the aorta. All these changes weaken the aortic wall leading to dilatation and aneurysm formation.
Aortic aneurysm is a late complication of the cardiovascular syphilis. The classic triad of ruptured aortic aneurysm is abdominal or back pain, hypovolaemic shock, and a pulsatile abdominal mass. Other complaints include pulsatile anterior chest wall mass, palpitations, dyspnea, chest pain which radiates to back, dysphagia, cough, and hemoptysis (due to tracheal compression).
History of primary syphilis History of primary syphilis is helpful in making the clinical suspicion of possible cardiovascular syphilis. History of primary syphilis
History of primary syphilis is helpful in making the clinical suspicion of possible cardiovascular syphilis.
Symptoms of brain abscess Septic embolization is a rare but a serious complication of syphilitic heart disease. Patients may complain of early morning headache, nausea, vomiting and focal neurological symptoms. Symptoms of brain abscess
Septic embolization is a rare but a serious complication of syphilitic heart disease. Patients may complain of early morning headache, nausea, vomiting and focal neurological symptoms.

Clinicals - Examination

Fact Explanation
Pulse Tachycardia and arrhythmia can be detected. Corrigan’s pulse is positive if significant aortic regurgitation is present. Pulse
Tachycardia and arrhythmia can be detected. Corrigan’s pulse is positive if significant aortic regurgitation is present.
Cardiac auscultation Tambour-like second heart sound is the most significant sign of aortic involvement. Aortic flow murmur can be heard as a rough systolic murmur over the aortic area. Cardiac auscultation
Tambour-like second heart sound is the most significant sign of aortic involvement. Aortic flow murmur can be heard as a rough systolic murmur over the aortic area.
Cardiomegaly Cardiomegaly is detected by the presence of laterally and inferiorly displaced cardiac apex. Cardiomegaly
Cardiomegaly is detected by the presence of laterally and inferiorly displaced cardiac apex.
Left ventricular hypertrophy The left ventricle is hypertrophied due to aortic regurgitation. Left ventricular hypertrophy
The left ventricle is hypertrophied due to aortic regurgitation.
Signs of heart failure Peripheral edema, pulmonary rales are detected due to heart failure. Signs of heart failure
Peripheral edema, pulmonary rales are detected due to heart failure.
Pulsation over the suprasternal notch Visible and palpable pulsations over the suprasternal notch can be detected in the presence of aortic aneurysm. Pulsation over the suprasternal notch
Visible and palpable pulsations over the suprasternal notch can be detected in the presence of aortic aneurysm.
Blood pressure Diastolic hypertension can be detected in some patients. The pulse pressure is increased in patients with aortic regurgitation. Blood pressure
Diastolic hypertension can be detected in some patients. The pulse pressure is increased in patients with aortic regurgitation.
Clinical signs of aortic regurgitation Quincke’s pulse (nail bed pulsations), Quincke’s pulse, wide pulse pressure, Duroziez’s murmur over the femoral artery, Traube’s sign (pistol shots femorals) and de Musset’s sign (head-nodding with each cardiac pulsations) Clinical signs of aortic regurgitation
Quincke’s pulse (nail bed pulsations), Quincke’s pulse, wide pulse pressure, Duroziez’s murmur over the femoral artery, Traube’s sign (pistol shots femorals) and de Musset’s sign (head-nodding with each cardiac pulsations)
Tracheal tug Tracheal tug is positive due to aortic root dilatation. Tracheal tug
Tracheal tug is positive due to aortic root dilatation.

Investigations - Diagnosis

Fact Explanation
Venereal Disease Research Laboratory (VDRL) test VDRL test is a simple and inexpensive test used to screen tertiary syphilis. However VDRL test is nonspecific and has many false positive results. Venereal Disease Research Laboratory (VDRL) test
VDRL test is a simple and inexpensive test used to screen tertiary syphilis. However VDRL test is nonspecific and has many false positive results.
Treponema pallidum haemagglutination assay (TPHA) TPHA test detects structural treponemal antigen. This is also simple and cheap screening test. Although TPHA is more specific than VDRL test, it can give rise to false positive results. Treponema pallidum haemagglutination assay (TPHA)
TPHA test detects structural treponemal antigen. This is also simple and cheap screening test. Although TPHA is more specific than VDRL test, it can give rise to false positive results.
FTA-ABS (fluorescent treponemal antibody test) FTA-ABS test is very sensitive in confirming the diagnosis of syphilis after the screening tests become positive. FTA-ABS (fluorescent treponemal antibody test)
FTA-ABS test is very sensitive in confirming the diagnosis of syphilis after the screening tests become positive.
Enzyme immunoassays (EIAs) EIAs detect the presence of Ig G and Ig M antibody subtypes indicating chronic and acute infection respectively. Enzyme immunoassays (EIAs)
EIAs detect the presence of Ig G and Ig M antibody subtypes indicating chronic and acute infection respectively.
Chest X-ray Chest X-ray shows the dilated aorta. If heart failure is present alveolar edema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusions can be seen. linear ‘eggshell’ configurations (calcium depositions) can also be seen in some patients. Wide mediastinum is seen in the presence of aortic aneurysm in tertiary syphilis. Chest X-ray
Chest X-ray shows the dilated aorta. If heart failure is present alveolar edema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusions can be seen. linear ‘eggshell’ configurations (calcium depositions) can also be seen in some patients. Wide mediastinum is seen in the presence of aortic aneurysm in tertiary syphilis.
ECG ECG shows the presence of arrhythmia (atrial fibrillation), bundle branch block and atrioventricular block. Evidence of myocardial ischemia like ST segment elevation, ST segment depression and T wave inversion can also be detected. These changes occur in tertiary syphilis. ECG
ECG shows the presence of arrhythmia (atrial fibrillation), bundle branch block and atrioventricular block. Evidence of myocardial ischemia like ST segment elevation, ST segment depression and T wave inversion can also be detected. These changes occur in tertiary syphilis.
Coronary angiogram Coronary angiogram can detect the site and the degree of the stenosis. Coronary artery stenosis is seen in about 26% of patients with syphilitic aortitis. Coronary angiogram
Coronary angiogram can detect the site and the degree of the stenosis. Coronary artery stenosis is seen in about 26% of patients with syphilitic aortitis.
Aortic root angiogram This helps in the assessment of aortic regurgitation an the aortic root dilatation in aortic aneurysm. Aortic root angiogram
This helps in the assessment of aortic regurgitation an the aortic root dilatation in aortic aneurysm.
Echocardiogram Valvular abnormalities can be visualized. Also helpful in assessing the degree of heart failure. Echocardiogram
Valvular abnormalities can be visualized. Also helpful in assessing the degree of heart failure.
Thoracic CT Thoracic CT can show the presence of aortic aneurysm especially when combined with angiogram. Thoracic CT
Thoracic CT can show the presence of aortic aneurysm especially when combined with angiogram.
Cardiac enzymes Cardiac enzymes are elevated in the presence of acute coronary syndrome. Cardiac enzymes
Cardiac enzymes are elevated in the presence of acute coronary syndrome.

Investigations - Management

Fact Explanation
Cerebrospinal fluid (CSF) analysis Cerebrospinal fluid analysis is indicated in all diagnosed patients to screen for the presence of neurosyphilis. Positive VDRL test and CSF cell count of more than 5 cells/mm3 and CSF protein or more than 40 mg/dl is diagnostic of neurosyphilis. Cerebrospinal fluid (CSF) analysis
Cerebrospinal fluid analysis is indicated in all diagnosed patients to screen for the presence of neurosyphilis. Positive VDRL test and CSF cell count of more than 5 cells/mm3 and CSF protein or more than 40 mg/dl is diagnostic of neurosyphilis.

Management - Supportive

Fact Explanation
Health education Syphilis is a sexually transmitted disease. Safe sex and use of barrier method of contraception are helpful in preventing the disease transmission. Early diagnosis and treatment of primary syphilis is necessary in preventing the occurrence of tertiary syphilis and subsequent complications of the disease.
All pregnant females should be screened for syphilis and treated if positive to prevent neonatal syphilis.
Health education
Syphilis is a sexually transmitted disease. Safe sex and use of barrier method of contraception are helpful in preventing the disease transmission. Early diagnosis and treatment of primary syphilis is necessary in preventing the occurrence of tertiary syphilis and subsequent complications of the disease.
All pregnant females should be screened for syphilis and treated if positive to prevent neonatal syphilis.
Management of heart failure Patients with heart failure are advised to have adequate rest and limit strenuous physical activities. Pharmacological management of heart failure includes beta blockers, angiotensin converting enzyme inhibitors, diuretics and digoxin. Revascularization, cardiac transplantation and left ventricular assisted devices are other treatment options. Management of heart failure
Patients with heart failure are advised to have adequate rest and limit strenuous physical activities. Pharmacological management of heart failure includes beta blockers, angiotensin converting enzyme inhibitors, diuretics and digoxin. Revascularization, cardiac transplantation and left ventricular assisted devices are other treatment options.
Management of angina Nitrates , beta-adrenergic blockers, and calcium channel blockers are used in the management of angina pectoris. Management of angina
Nitrates , beta-adrenergic blockers, and calcium channel blockers are used in the management of angina pectoris.
Management of coronary artery stenosis Percutaneous transluminal coronary angioplasty (PTCA) can be done. Coronary artery bypass graft and stenting can also be done in patients. Management of coronary artery stenosis
Percutaneous transluminal coronary angioplasty (PTCA) can be done. Coronary artery bypass graft and stenting can also be done in patients.
Management of aortic aneurysms Some patients with aortic aneurysm can be left untreated. Open surgery or endovascular stenting is available treatment options for the management of symptomatic aneurysms or if aneurysms are increased risk of rupture. Management of aortic aneurysms
Some patients with aortic aneurysm can be left untreated. Open surgery or endovascular stenting is available treatment options for the management of symptomatic aneurysms or if aneurysms are increased risk of rupture.
Management of arrhythmia Antiarrhythmic drugs are indicated for the treatment of arrhythmia. Management of arrhythmia
Antiarrhythmic drugs are indicated for the treatment of arrhythmia.

Management - Specific

Fact Explanation
Benzathine penicillin G Intravenous penicillin (6 to 10 million units) should be given for 2 to 3 weeks. Patients who are sensitive to penicillin can be treated with tetracycline. Herxheimer reaction (Vasodilation and edema of the site of lesion, when occurs at the sites of coronary artery stenosis it leads to further narrowing of the coronary artery and may lead to a myocardial infarction.) is a potential complication of treatment with penicillin and arsenic. Benzathine penicillin G
Intravenous penicillin (6 to 10 million units) should be given for 2 to 3 weeks. Patients who are sensitive to penicillin can be treated with tetracycline. Herxheimer reaction (Vasodilation and edema of the site of lesion, when occurs at the sites of coronary artery stenosis it leads to further narrowing of the coronary artery and may lead to a myocardial infarction.) is a potential complication of treatment with penicillin and arsenic.
Arsenic Intramuscular or intravenous arsenic is used in the treatment. Arsenic
Intramuscular or intravenous arsenic is used in the treatment.

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