Syphilis - S Abraham

CASE PRESENTATION
S. Abraham

A.Y, 53yr Indian Male
Hx: Hx:
one day history
Typical chest pain
Grade NYHA 3-4 3
3 pillow orthopnoea
Class 2-3 2 3 angina and Grade 2 NYHA dyspnoea
for past 2years
PMHx:
Previous anteroseptal MI with left ventricular
dysfunction(EF 18) and L parietal CVA
secondary to intracardiac thrombus in 2006.On
Warfarin.
Aortic regurgitation diagnosed 2006

History cont..
PSHx: PSHx:
nil
Allergies:Nil
Allergies:Nil
Social Hx : Smoking history 60pack years
Never consumed alcohol or other
drugs
self-employed self employed businessman
Family history-No history No history IHD

Examination
Well looking middle aged male
Conscious and co-operative
co operative
Distressed
No pallor, cyanosis, oedema
No skin lesions

Examination cont..
BP: 131/54, equal in all limbs
Pulse: 76/min, regular, low volume, all
pulses equal and palpable
RESP: RESP
RR 28/min
Increased AP diameter
Hyperinflated,liver dullness 7 th ICS
Bibasal crepitations

CVS
JVP raised 5cm
Examination cont…. cont
Apex 6 th ICS AAL,hypodynamic
L parasternal heave present
EDM 2/4 aortic area,loudest left sternal
border
Loud P2

Examination cont… cont
ABD: ABD
Soft ,non tender
Shifting dullness present
CNS: CNS:
normal higher mental function
no meningism
no focal motor,sensory ,motor or
cerebellar signs

ECG

Summary
52 year old male with background of CAD
and LV dysfunction and strong smoking
history
Congestive cardiac failure in the setting of
ACS
COPD
Aortic regurgitation for further investigation

Valvular
Rheumatic heart Disease(unlikely)
Disease(unlikely
Syphilis
Rheumatoid spondylosis
Infective endocarditis
Aortic root
HPT
Artherosclerosis
Syphilis
Collagen vascular ds-Takayasus
ds Takayasus
Rheumatoid Ankylosing spondylosis

Investigations
FBC: WCC 6.7/Hb 13.8/MCV 93/Plts 173
U&E: Na 137/K 4.6/Cl 108/CO2 24/U 24/
12.5/Creat 129
Clotting profile :INR : INR 5.32
Cardiac enzymes: Trop I >100,CK 894
LFTs: LFTs:
ALP 49/Tbil 15/TP 61/Alb 36/GGT
32/ALT 49
Lipid profile:Tg 1.03/Chol 4.5/HDL
0.68/LDL 3.4

Investigations cont… cont
HIV negative
RPR positive(Titre 1:64)
Lung function tests
FEV1/FVC-(1.47/2.09)
FEV1/FVC (1.47/2.09) 70 70 % with no
reversibility

CXR

E
C
H
O
:
Echo
MV
Ao V
LV
LA
PV
RV
RA
TV
Peric
Minimal thickening, trace
MR
Min thickening, mod AR,
Syst peak flow1.5m/s,Ao
root 30mm
Dilated, EF 40,EDD 89,
ESD 70, FS 18
Dilated 60mm
N
Dilated
Mildly dilated
N,PAS 34
N

Management and progress
Managed as Non ST elevation Myocardial
infarction`and diuresis optimised. optimised
Subsequent angiogram showed normal
coronaries with global hypokinesis
TPHA positive and treated with
Benzathine Penicillin 2.4 MU weekly for 3
weeks

LP done –normal normal
Polys nil/ Lymp nil/TP 0.26/Globulin no
increase/Glu
increase/ Glu 3.26/ VDRL and
FTA-AB FTA AB pending
Presented to IALCH for AVRnot AVR not for
surgery

52 year old male with Tertiary Syphilis
with Cardiovascular complications
Aortic regurgitation
Coronary artery involvement
COPD

TERTIARY SYPHILIS

SYPHILIS
Chronic infectious disease caused by
Treponema pallidum
Management is based on 3 stages of disease:
EARLY: primary/ secondary/latent
LATE OR TERTIARY:
- Cardiovascular
- Gummatous syphilis
- Neurosyphilis

EPIDEMIOLOGY
Common in preantibiotic era in 20-30% 20 30% of
pts with syphilis
Currently common in patients with HIV -
often have early neurosyphilis, neurosyphilis,
most
commonly asymptomatic and symptomatic
meningitis, with ocular disease

PATHOGENESIS
Cellular immunity plays a role
Waning immunity with age allows reactivation of
the spirochete that have sequestered in these
sites.
Alternatively re infection occurs in a partially
immune hypersensitive host leading to a chronic
inflammatory response.(gummas)
response.(gummas
Small vessel vasculitis

GUMMATOUS SYPHILIS
Skin, bones, or internal organs
Range from small to very large
Visceral gummas may present as a mass
lesion

CARDIOVASCULAR SYPHILIS
Small vessel vasculitis affecting vasa vasorum
Usually involves ascending thoracic aorta- aorta Aortic
aneurysm( aneurysm( rarely dissection)
Aortic valve regurgitation
Coronary arteries
- involvement
involvement
- narrowing &
- thrombosis

CVS cont…. cont
Most present with asymptomatic murmur,
or left heart failure
Occur 15-30 15 30 yrs from initial Ix
CXR CXR calcification ascending arch of
aorta (not seen with arterosclerosis)
arterosclerosis
Coronary ostial stenosis may be found on
catheterization

NEUROSYPHILIS
Can occur any time after initial infection
Early disease involves: CSF, meninges, meninges,
and
vasculature
- Asymptomatic meningitis
- Symptomatic meningitis
- Meningovascular disease
Late disease involves brain and spinal cord
- General paresis of insane
- Tabes dorsalis

Asymptomatic Meningitis
No symptoms or signs of CNS
Can occur within wks – months after Ix,
uncommonly >2yrs after Ix
CSF: lymphocytic pleocytosis >20cells
/ul ul, , protein (0.46-1), (0.46 1), positive VDRL

Symptomatic meningitis
Often occurs within 1 st yr after Ix
uncommonly yrs later
Symptoms: headache, confusion, N & V,
and stiff neck
Uveitis, Uveitis,
retinitis, or optic neuritis
Leptomeningitis,Gumma
Cranial neuropathy common: CNII, CNVII,
CNVIII
Hydrocephalus

Arteritis of small,medium or large vessels
Seizures
Uncommonly affects Spinal Cord:
meningomyelitis,
meningomyelitis,
polyradiculopathy,
polyradiculopathy,
hyperplastic
pachymeningitis
CSF AbN: AbN:
lymphocyte 200-400, 200 400, protein
100-200mg/dl, 100 200mg/dl, VDRL always +
Imaging: features of meningitis &/or gummas

Meningovascular syphilis
Infectious arteritis-> arteritis > thrombi & infarcts
Onset any time from 1sr months- months 1 st few years,
average 7yrs
May be seen as stroke in young person
Prodromal symptoms present
Acute or chronic stroke usually of MCA branches,
rarely Ant spinal A.-> A. > SC infarct
CSF abN: abN:
lymphocyte pleocytosis 10-100 10 100 &
protein 100-200, 100 200, VDRL usually positive
CSF

General paresis
Progressive dementing illness
usually 10-25 10 25 yrs after Ix
chronic progressive frontotemporal
meningoencephalitis with loss of
cortical function
early stage: forgetfulness
late stage : severe dementia

P – personality
A – affect
R – reflexes (brisk)
E – eye (Argyll Robertson pupil)
S – sensorium (illusions, delusions)
I – intellect (memory, calculation,
orientation, judgement, judgement,
insight)
S – Speech (dysarthric ( dysarthric)

MRI:
frontocortical atrophy, frontal high-signal high signal
lesions, cerebral atrophy
mesiotemporal T2 hyperintensity
ventriculomegaly
pathological T2 hypointensity of Basal
ganglia & thalamus
diffuse white matter T2 hyperintensity

Tabes dorsalis
Disease of the posterior columns of the spinal
cord and the dorsal roots.
Longest latent period average 20 yrs.
CSF : normal/mild lymphocytic pleocytosis with
10 to 50 cells/µL cells/ L and protein concentrations of
0.45 to 0.75 .1/4 cases VDRL non reactive.

Triad of Symptoms
- Lancinating pains
- Bladder incontinence / sexual dysfunction
- Ataxia
Triad of Signs
- Argyll Robertson pupil
- Loss of reflexes
- Loss of proprioception, proprioception,
vibration sense

Diagnosis
Darkfield microscopy (3x),DFA-TP
(3x),DFA TP
Serological
Non-specific
Non specific – titres reflect disease activity
RPR/VDRL(positive
RPR/ VDRL(positive titres>1:32)
titres>1:32)
Specific
– confirm non-specific non specific tests
FT-ABs,MHA
FT ABs,MHA
CSF-VDRL,FTA CSF VDRL,FTA AB

Treatment
Aimto Aim to prevent progression of disease
Gummatous
Benzathine penicillin 2.4 MU once wkly x 3
Alternatives: Doxycycline,Ceftriaxone
Cardiovascular
Benzathine Penicillin
Alternatives:Ceftriaxone

Treatment cont… cont
Neurosyphilis
IV Penicillin G 10-14 10 14 days
Alternatives(not recommended)
- Procaine penicillin plus Probenecid
- Amoxycillin plus probenecid
- Doxycycline
Same regimen for ocular/auditory

Followup …
Serum VDRL at 3 and 6 months,thereafter
6 monthly for 2 years
Drop in titres fourfold serum VDRL
CSF 6monthly until cell count normalises
All sexual contacts should be treated

Harrison 16 th edit
Up to date
References