A 68-year-old man develops orthopnea and paroxysmal nocturnal dyspnea, worsening over the past 3 years. A chest xray shows linear calcification of the ascending aorta. On physical examination, auscultation of the chest reveals a regular heart rate and rhythm, but there is a murmur of aortic regurgitation. Echocardiography reveals aortic root dilation to 4 cm.

Question 8.1 - What are the cardiovascular manifestions seen here?

There is dilation of the aortic root with aortic valvular insufficiency and resultant left-sided congestive heart failure.

Question 8.2 - What laboratory test(s) would you order?

VDRL, FTA-ABS

Question 8.3 - What is the diagnosis?

This is the late (tertiary) stage of syphilis, due to Treponema pallidum infection, a sexually transmitted disease.

Question 8.4 - Explain the pathophysiology for this condition.

Cardiovascular manifestations are attributable to endarteritis obliterans of the vasa vasorum, which provide the blood supply to large vessels. This condition produces medial necrosis with destruction of elastic tissue, particularly in the ascending and transverse segments of the aortic arch, resulting in uncomplicated aortitis, aortic regurgitation, saccular aneurysm, or coronary ostial stenosis.

In the preantibiotic era, symptomatic cardiovascular complications developed in about 10% of persons with late untreated syphilis, and aortic regurgitation was two to four times as common as aneurysm. However, syphilitic aortitis was demonstrated at autopsy in about one-half of African-American men with untreated syphilis.