Syphilis is a mainly sexually transmitted infection that may show a variety of symptoms at various stages. Syphilitic aortitis is a known complication of tertiary syphilis and can cause aneurysm of the aorta.1 In the era of antibiotics, cardiovascular syphilis has become very rare.2 Nevertheless it can cause life-threatening or even fatal symptoms and should therefore be diagnosed at an early stage.3
A man in his 70s presented with a 4-week history of an asymptomatic eruption, bilateral lymphadenopathy, and slightly reduced general condition. Physical examination revealed generalized dark purple scaly plaques and nodules (Figure 1) involving soles and palms.
Dark purple scaly plaques and nodules on the thighs.
Routine laboratory tests showed elevated C-reactive protein and liver enzyme levels. Hematoxylin-eosin staining of a tissue specimen demonstrated an inflammatory infiltrate with some plasma cells. Immunohistochemical findings were positive for Treponema pallidum. Serologic results were negative for human immunodeficiency virus and hepatitis. The results for the VDRL (Venereal Disease Research Laboratory test) (1:128), TPPA (Treponema pallidum particle agglutination assay) (1:10240), and FTA-Abs (fluorescent treponemal antibody-absorption) IgG test were positive, and the level of 19S IgM FTA-Abs was marginally elevated, confirming the diagnosis of syphilis. Ocular and neurologic involvement was excluded. A chest radiograph showed an enlarged aortic contour suggestive of dilative aortic angiopathy without any signs of aneurysm. Radiographic computed tomography (CT) demonstrated thickening of the aortic wall and aortic sclerosis in the transverse plane. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) alongside CT (PET/CT) demonstrated a maximum isotope uptake of the descending aorta, confirming the suspected diagnosis of an aortitis (Figure 2). We thus diagnosed secondary syphilis with asymptomatic aortitis. To prevent aortic rupture triggered by massive cell disintegration of T pallidum microorganisms (Herxheimer reaction), we implemented a prophylaxis with 100-mg prednisolone prior to the antibiotic therapy with penicillin G, 6 × 5 Mio IU/d, over a 2-week period.
A, 18F-Fluorodeoxyglucose (18F-FDG)positron emission tomography (PET) demonstrates a maximum isotope uptake of the descending aorta. B, 18F-FDG PET alongside computed tomography (CT) clearly demonstrates the maximum isotope uptake of the descending aorta. C, Radiographic CT demonstrates thickening of the aortic wall and aortic sclerosis in the transverse plane.
Syphilitic aortitis is a potential serious complication of usually chronic tertiary syphilis.4 It is exceedingly rare in secondary syphilis, as seen in our patient. It often is an incidental radiologic finding, and signs of infection (eg, fever and leukocytosis) are often missing. Performing 18F-FDG–PET/CT scan may allow the early diagnosis of syphilitic aortitis at a subclinical stage and prevent life-threatening or fatal outcome.5,6
Corresponding Author: Andreas Dietrich, MD, Department of Dermatology and Allergy, Ludwig-Maximilian-University, Frauenlobstr 9-11, 80337 Munich, Germany (firstname.lastname@example.org).
Published Online: March 5, 2014. doi:10.1001/jamadermatol.2013.9537.
Conflict of Interest Disclosures: None reported.
Additional Information: Drs Dietrich and Gauglitz contributed equally to this article.
Dietrich A, Gauglitz GG, Pfluger TT, Herzinger T, Braun-Falco M. Syphilitic Aortitis in Secondary Syphilis. JAMA Dermatol. 2014;150(7):790-791. doi:10.1001/jamadermatol.2013.9537