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Syphilitic Angina
CLINICAL COMMUNICATION TO THE EDITOR
Syphilitic Angina To the Editor: A 49-year-old man from El Salvador presented with classic angina. He had no risk factors for atherosclerosis. Electrocardiogram demonstrated 2-mm ST depression in leads II and III, and augmented voltage left foot lead (AVF); troponins were elevated. The chest radiograph showed normal heart size and aorta. Echocardiogram showed hypokinesis of the inferior wall with very mild aortic regurgitation. Coronary angiography showed severe narrowing of the proximal 10 mm of the right coronary artery (Figure 1). Beyond that, the right coronary artery and the left coronary artery were normal. Reconstructed computed tomographic imaging showed a normal-sized ascending aorta and severe narrowing of the proximal right coronary artery (Figure 2). The patient was treated for syphilis because of his history of unprotected sex and ulcer on his penis years earlier, and had a rapid plasma reagin titer of 1:32. Tertiary syphilis affecting the aorta is primarily an arteritis of the vasa vasorum,1 which may lead to formation of a saccular aneurysm; it may extend down into the annulus, resulting in severe aortic regurgitation. Fibrosis of the media may result in thickening of the aortic wall and prevention of aortic wall dilatation. The fibrosis can extend beyond the ascending aorta to involve the proximal portion of the coronary arteries, the arch, and the branches of the arch of the aorta, which this patient demonstrated. Routine anti-anginal treatment provided modest relief. Our goal was to extend the studies of the arch to evaluate the innominate artery and the proximal portion of the subclavian artery. If the subclavian and the origin of the right internal mammary artery were unaffected, the goal was to implant the right internal mammary artery to the right coronary artery beyond the narrowing. The patient wanted to defer additional testing and possible surgery to a time in the future.
Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data. All authors had a role in writing the manuscript, have read the manuscript, and agree with its content. Requests for reprints should be addressed to Shahbudin H. Rahimtoola, MD, LAC USC Medical Center, Old GNH Room 3221, Los Angeles, CA 90033. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2013 Elsevier Inc. All rights reserved.
Figure 1 Coronary arteriogram showing narrowing of the ostium and that of the proximal 10 mm of the right coronary artery.
Figure 2 Reconstruction of contrast-enhanced multislice computed tomography scan of the heart. The arrow points to the narrowing of the proximal portion of the right coronary artery and its ostia. Note that there is no dilatation of the ascending aorta and of the aortic root.
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The American Journal of Medicine, Vol 126, No 9, September 2013 Henry Chu, MD Diana Arsene, MD Grace Huang, MD Farhood Saremi, MD Shahbudin H. Rahimtoola, MB, DSc (Hon) Griffith Center Division of Cardiovascular Medicine Department of Medicine LACþUSC Medical Center
Keck School of Medicine University of Southern California Los Angeles
http://dx.doi.org/10.1016/j.amjmed.2013.03.015
Reference 1. Roberts CR, Ko JM, Vowels TJ. Natural history of syphilitic aortitis. Am J Cardiol. 2009;104:1578-1587.
Syphilitic Angina To the Editor: A 49-year-old man from El Salvador presented with classic angina. He had no risk factors for atherosclerosis. Electrocardiogram demonstrated 2-mm ST depression in leads II and III, and augmented voltage left foot lead (AVF); troponins were elevated. The chest radiograph showed normal heart size and aorta. Echocardiogram showed hypokinesis of the inferior wall with very mild aortic regurgitation. Coronary angiography showed severe narrowing of the proximal 10 mm of the right coronary artery (Figure 1). Beyond that, the right coronary artery and the left coronary artery were normal. Reconstructed computed tomographic imaging showed a normal-sized ascending aorta and severe narrowing of the proximal right coronary artery (Figure 2). The patient was treated for syphilis because of his history of unprotected sex and ulcer on his penis years earlier, and had a rapid plasma reagin titer of 1:32. Tertiary syphilis affecting the aorta is primarily an arteritis of the vasa vasorum,1 which may lead to formation of a saccular aneurysm; it may extend down into the annulus, resulting in severe aortic regurgitation. Fibrosis of the media may result in thickening of the aortic wall and prevention of aortic wall dilatation. The fibrosis can extend beyond the ascending aorta to involve the proximal portion of the coronary arteries, the arch, and the branches of the arch of the aorta, which this patient demonstrated. Routine anti-anginal treatment provided modest relief. Our goal was to extend the studies of the arch to evaluate the innominate artery and the proximal portion of the subclavian artery. If the subclavian and the origin of the right internal mammary artery were unaffected, the goal was to implant the right internal mammary artery to the right coronary artery beyond the narrowing. The patient wanted to defer additional testing and possible surgery to a time in the future.
Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data. All authors had a role in writing the manuscript, have read the manuscript, and agree with its content. Requests for reprints should be addressed to Shahbudin H. Rahimtoola, MD, LAC USC Medical Center, Old GNH Room 3221, Los Angeles, CA 90033. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2013 Elsevier Inc. All rights reserved.
Figure 1 Coronary arteriogram showing narrowing of the ostium and that of the proximal 10 mm of the right coronary artery.
Figure 2 Reconstruction of contrast-enhanced multislice computed tomography scan of the heart. The arrow points to the narrowing of the proximal portion of the right coronary artery and its ostia. Note that there is no dilatation of the ascending aorta and of the aortic root.
e4
The American Journal of Medicine, Vol 126, No 9, September 2013 Henry Chu, MD Diana Arsene, MD Grace Huang, MD Farhood Saremi, MD Shahbudin H. Rahimtoola, MB, DSc (Hon) Griffith Center Division of Cardiovascular Medicine Department of Medicine LACþUSC Medical Center
Keck School of Medicine University of Southern California Los Angeles
http://dx.doi.org/10.1016/j.amjmed.2013.03.015
Reference 1. Roberts CR, Ko JM, Vowels TJ. Natural history of syphilitic aortitis. Am J Cardiol. 2009;104:1578-1587.