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Cardiovascular syphilis 

Cardiovascular syphilis

Chapter:
Cardiovascular syphilis
Author(s):

Krishna Somers

DOI:
10.1093/med/9780199204854.003.160904_update_003

Update:

Management – use of 18F-FDG PET/CT for assessment of disease and response to treatment.

Updated on 27 Nov 2014. The previous version of this content can be found here.
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date: 30 March 2017

Clinicians need to be aware of cardiovascular syphilis in patients at risk of infection, with the time taken from initial infection to clinical manifestation ranging from 10 to 25 years, although this is accelerated in patients with HIV infection. Inadequate or interrupted antibiotic therapy may confound the development of cardiovascular syphilis and make diagnosis difficult.

Presentation may be with (1) asymptomatic aortitis; (2) aortic regurgitation—the commonest manifestation resulting from annular dilatation of the aortic ring and eventually affecting 70% of patients with untreated syphilis; (3) coronary ostial stenosis; (4) aneurysm of the aorta; or (5) a combination of these. Syphilitic aortitis must be included in the differential diagnosis of aortic regurgitation in older people and those with predisposing factors.

Diagnosis—serological testing is the mainstay: latent or inadequately treated syphilis should be suspected with the finding of a positive nonspecific treponemal serological test (e.g. rapid plasma reagin, RPR) and a positive specific treponemal antibody test (e.g. Treponema pallidum haemagglutination, TPHA), but negative serology does not absolutely exclude infection with T. pallidum, particularly in an immunocompromised host.

Management—parenteral penicillin remains the treatment of choice for cardiovascular syphilis: the World Health Organization and European and United States guidelines recommend benzathine penicillin 2.4 × 106 units administered once weekly for 3 weeks by the intramuscular route. Modern imaging technology with MRI and three-dimensional CT enables innovative surgical approaches in the repair of syphilitic aortitis.

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