J Thorac Cardiovasc Surg 2007;133:1085-1086
© 2007 The American Association for Thoracic Surgery
Intramural hematoma and thoracic aortic aneurysm with syphilis
Mitsuru Asano, MD*,
Ohtake Hiroshi, MD,
Yuji Hanafusa, MD,
Hiroshi Kazuma, MD,
Masahiro Tanji, MD
Department of Cardiovascular Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama City, Fukushima, Japan.
Received for publication November 14, 2006; accepted for publication November 20, 2006.
* Address for reprints: Dr Mitsuru Asano, Department of Cardiovascular Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama City, Fukushima prefecture 963-8558, Japan. (Email: manasano{at}med.kobe-u.ac.jp).
Syphilitic aortitis is usually associated with aortic aneurysm, aortic regurgitation, and coronary ostial stenosis.1
However, aortic dissection and intramural hematoma (IMH) due to syphilitic aortitis have rarely been reported. We present a case of ascending aortic IMH and aortic arch aneurysm with syphilis; the patient underwent total arch replacement.
Clinical Summary
A 76-year old woman was admitted because of continuous low-grade pyrexia. The chest computed tomographic scan (CT) revealed ascending aortic IMH (55 mm) and aneurysm (65 mm) of the aortic arch (Figure 1). Results of the treponema pallidum hemagglutination test was positive; however, the result of the serologic test for syphilis was negative, which revealed past syphilitic infection. Total arch replacement with selective antegrade cerebral perfusion and deep hypothermic circulatory arrest in the lower body was performed. The severe adhesion with the pericardial cavity and thickened aortic wall suggested existence of an old inflammatory event. In the ascending aorta, there was IMH without an intimal tear. The culture of aortic wall and hematoma was negative; however, the pathology of the ascending aorta revealed diffuse infiltration of lymphocyte and plasma cells in the adventitia (Figure 2). The postoperative course was uneventful.
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Figure 1. The chest CT revealed ascending aortic IMH (55 mm) (left) and aortic arch aneurysm (65 mm) (right).
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Figure 2. The pathology of the ascending aorta revealed inflammatory cellular infiltration of lymph corpuscle and plasma cells in adventitia.
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Discussion
Cardiovascular syphilis mainly occurs in the third stage of syphilis and is likely to appear in the ascending aorta and aortic arch. Syphilitic aortitis is followed by aortic aneurysm (40%), rupture (14%), aortic valve regurgitation (29%), and coronary ostial stenosis (26%).1 However, aortic dissection due to syphilitic aortitis has rarely been reported to date, probably because of scar tissue formation in the aortic wall. Histologically, both the intima and adventitia are cicatrized and thickened after inflammation of syphilitic aortitis.2 We could find only 2 cases of syphilitic aortic dissection3,4 and syphilitic IMH.5 IMH is a type of aortic dissection and is regarded as hematoma with neither intimal flap nor direct blood communication between false and true lumen.
In this case, IMH was diagnosed by preoperative CT and operative findings. The pathologic study of the ascending and aortic arch revealed inflammatory cellular infiltration of lymphocyte and plasma cells in adventitia that is characteristics of syphilitic aortitis. We thought the IMH was caused by the rupture of vasa vasorum of fragile media after syphilitic aortitis and by cicatrized intima and adventitia.
References
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- Svesson LG, Crawford ES. Cardiovascular and vascular disease of the aorta. Philadelphia: W.B. Saunders; 1997.
- Tai YT, Mok CK, Chow WH, Chan FL, So KF. Ascending aortic dissection complicating syphilitic aortitis, late after aortic valve replacement. Clin Cardiol 1990;13:227-229.[Medline]
- Kallett MW, Young GR, Fletcher NA. Paraparesis due to syphilitic aortic dissection. Neurology 1997;48:221-223.[Abstract/Free Full Text]
- Chauvel C, Cohen A, Albo C, Ziol M, Valty J. Aortic dissection and cardiovascular syphilis: report of an observation with transesophageal echocardiography and anatomopathologic findings. J Am Soc Echocardiogr 1994;7:419-421.[Medline]
