Aortitis sifilítica: a propósito de un caso del sur colombiano / Syphilitic aortitis: about a case in South Colombia

Resumen Se expone el caso de una paciente de 73 años procedente y residente de Florencia, Caquetá (Colombia), con antecedentes de hipertensión arterial, que ingresa a un hospital de alta complejidad por un cuadro clínico de 3 meses de evolución consistente en dolor torácico tipo opresivo en la región anterior izquierda del tórax, no irradiado, de intensidad 8/10. En el ecocardiograma se evidencia enfermedad calcificada de la válvula aórtica con estenosis aortica grave, insuficiencia aórtica, hipertrofia del ventrículo izquierdo e insuficiencia mitral leve. Dentro de los estudios prequirúrgicos presentó VDRL con 1:4 diluciones, se confirmó el diagnóstico con el resultado de la prueba treponémica y se descartaron otras enfermedades infecciosas. Se realizó remplazo valvular con bioprótesis y tubo valvular supracoronario. En la biopsia se confirmó la valvulitis crónica cicatricial con extensas calcificaciones. Posterior a la intervención quirúrgica se dio egreso por adecuada evolución clínica.

Abstract The case of a 73-year-old female patient obtained and resident of Florencia, Caquetá (Colombia), with a history of hypertension who is admitted to a highly complex hospital due to a 3-month clinical picture of constant evolution in pain is presented. Thoracic oppressive type in the anterior region of the left thorax, non-irradiated, of intensity 8/10. The echocardiogram shows calcified aortic valve disease with severe aortic stenosis, aortic regurgitation, left ventricular hypertrophy, and mild grade mitral regurgitation. Within the pre-surgical studies, she presented VDRL with 1:4 dilutions and the diagnosis was confirmed with the result of the treponemal test and other infectious diseases were ruled out. Valvular replacement was performed with a bioprosthesis plus a supra-coronary valvular tube. In the biopsy, chronic scar valvulitis with extensive calcifications was confirmed. After the surgical intervention, discharge was performed due to adequate clinical evolution.

Aortitis sifilítica: manifestación olvidada de la sífilis / Syphilitic aortitis: forgotten manifestation of syphilis

Resumen La sífilis es una infección bacteriana producida por el Treponema pallidum (espiroqueta). Consta de varias etapas: primaria, secundaria y terciaria, según el tiempo de evolución desde el momento en que se adquiere la infección. Cada etapa comprende diferentes manifestaciones clínicas; los síntomas cardiovasculares forman parte de la sífilis terciaria, en cuyo caso la aortitis sifilítica es la principal forma de presentación. Se expone el caso de un paciente que consultó por déficit neurológico focal, en quien por medio de estudios de extensión se documentó neurosífilis e insuficiencia valvular aórtica severa secundaria a perforación de la válvula coronaria derecha, que requirió recambio valvular aórtico por bioprótesis. Adicionalmente, se hace una revisión de las principales manifestaciones cardiovasculares de esta enfermedad. Aunque en la era postantibiótica este tipo de manifestaciones tardías son cada vez menos frecuentes, es imperativo conocerlas.

Abstract Syphilis is a bacterial infection caused by Treponema pallidum (spirochete). It has various stages: primary, secondary and tertiary; depending on the time to progression from the moment the infection is acquired. Each stage involves various clinical manifestations; cardiovascular symptoms are part of tertiary syphilis, and syphilitic aortitis is the main form of presentation. We present the case of a patient who consulted with a focal neurological deficit, in whom extension studies reported neurosyphilis and severe aortic failure secondary to perforation of the right coronary valve, which required aortic valve replacement by bioprosthesis. We also undertake a review of the main cardiovascular manifestations of this disease. Although in the post-antibiotic era this type of late manifestation is increasingly less frequent, it is imperative that we are aware of it.

Aortitis: Hallazgos radiológicos en relación a sus diversas etiologías / Aortitis: Radiological Findings in Relation to its Various Etiologies

Resumen La inflamación de la aorta (aortitis) es una patología poco frecuente, con etiología infecciosa (pseudoaneurisma micótico, sífilis) y no infecciosa (arteritis, aortitis idiopática, espondilitis anquilosante, entre otras) de difícil diagnóstico clínico y variable pronóstico. Por esa razón, la utilización de diversos métodos por imágenes, tales como la tomografía computada multidetector (TCMD), la tomografía computada por emisión de positrones (PET-TC), la resonancia magnética (RM) y ultrasonido (US) facilitan la identificación, seguimiento y tratamiento de esa entidad. El siguiente trabajo tiene como objetivo realizar una revisión y actualización bibliográfica acerca de la aortitis y sus diversas etiologías, ejemplificando con casos de nuestra institución.

Abstract Aortic inflammation (aortitis) is a rare pathology, with infectious (fungal pseudoaneurysm, syphilis) and noninfectious etiology (arteritis, idiopathic aortitis, ankylosing spondylitis, among others), it has a difficult clinical diagnosis and a variable prognosis. The use of various imaging methods such as multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT) and ultrasound (US) facilitate the identification, monitoring and treatment of this entity. The following paper aims to perform a literature review and update about aortitis and its various etiologies, exemplifying cases of our institution.

Aortitis sifilítica: "una vieja olvidada" / Syphilitic aortitis: Old and forgotten. Report of a case

Resumen Se expone el caso de un paciente de sexo masculino, de 69 años, con antecedentes de hipertensión arterial, tabaquismo, ataque cerebrovascular, fibrilación auricular, insuficiencia aórtica y cardiopatía isquémica, quien ingresa a un hospital de alta complejidad por deterioro de la clase funcional, edema de miembros inferiores y episodios de palpitaciones. En la ecocardiografía se halló fracción de eyección normal, insuficiencia aórtica grave y dilatación de aorta ascendente con criterios quirúrgicos. Dentro de los estudios prequirúrgicos, se documentó VDRL reactivo en títulos altos y confirmación del diagnóstico de sífilis con TP-PA. Se realizó reemplazo valvular aórtico con prótesis biológica e injerto de dacrón en aorta ascendente, y el estudio patológico del material quirúrgico confirmó aortitis sifilítica. Se presenta una revisión respecto a esta patología poco frecuente en la actualidad.

Abstract The case is presented of a 69-year-old male patient with a history of arterial hypertension, smoking, stroke, atrial fibrillation, aortic regurgitation, and ischaemic heart disease, who was admitted to a tertiary hospital due to functional class deterioration, lower limb oedema, and episodes of palpitations. A normal ejection fraction, with severe aortic regurgitation and ascending aortic dilation with surgical criteria, was found on echocardiography. Within pre-surgical studies, the VDRL had high titres and confirmation of the diagnosis of syphilis with TP-PA. Aortic valve replacement was performed using a biological prosthesis and Dacron graft in the ascending aorta. The histopathology study of the surgical material confirmed syphilitic aortitis. A review is presented on the current status of this rare pathology.

Importance of anatomopathological analysis and histopathological examination for the diagnosis of suspected cases of syphilitic aneurysm / Importância da análise anatomopatológica e histopatológica para o diagnóstico de casos suspeitos de aneurisma sifilítico

Introduction: syphilis is a sexually transmitted disease caused by mycobacterium Treponema pallidum in which in its tertiary stage can lead to an aortic syphilitic aneurysm. Currently, such cases are rare because of the effectiveness of antibiotic therapy. Objective: we aimed to carry out an anatomopathological analysis and histopathological examination of three cases potentially suspicious of aortic syphilitic aneurysm on human corpses. Methods: It was a descriptive study which 03 anatomic specimens of aortas from cadavers with ages ranging from 50 to 91 years obtained in Service checklist of deaths during the period from 2014 to 2015. We performed an anatomopathological and histopathological analysis with the use of special dyes. Results: through the macroscopic evaluation it was observed in all cases a dilation corresponding to arch of aorta where the intima obtained an aspect of longitudinal striation, classic of syphilitic process. As for histopathological study on the tissues treatment with the staining batteries, it was demonstrated the presence of the dissecting hematoma in all cases, besides necrosis and absence characteristic of the inflammatory process. Conclusion: the anatomopathological and histopathological study are diagnostic tools which have specific characteristics and are directed to assist in preliminary diagnosis of suspected cases of aortic syphilitic aneurysm in necropsies.

Introdução: a sífilis é uma doença sexualmente transmissível causada pela micobactéria Treponema pallidum em que, em seu estágio terciário, pode levar à um aneurisma aórtico sifilítico. Atualmente, esses casos são raros devido à eficácia da terapia com antibióticos. Objetivo: objetivou-se realizar uma análise anatomopatológica e exame histopatológico de três casos potencialmente suspeitos de aneurisma sifilítico aórtico em cadáveres humanos. Métodos: Estudo descritivo que avaliou 03 amostras anatômicas de aortas oriundas de cadáveres com idades variando de 50 a 91 anos, obtidas no Verificação de Serviço de óbitos no período de 2014 a 2015. Realizamos uma análise anatomopatológica e histopatológica com o uso de corantes especiais. Resultados: através da avaliação macroscópica observou-se em todos os casos uma dilatação correspondente ao arco de aorta onde a íntima obteve um aspecto de estriado longitudinal, clássico do processo sifilítico. Quanto ao estudo histopatológico dos tecidos tratados com as baterias de coloração, foi demonstrada a presença do hematoma dissecante em todos os casos, além da necrose e ausência característica do processo inflamatório. Conclusão: o estudo anatomopatológico e histopatológico são ferramentas diagnósticas com características específicas e orientadas a auxiliar no diagnóstico preliminar de casos suspeitos de aneurisma sifilítico aórtico em necropsias.

Aneurisma del tronco de la coronaria izquierda e insuficiencia aórtica de origen sifilítico.: Reporte de un caso y revisión de la literatura / Aneurysm of the left main coronary artery and aortic insufficiency of syphilitic origin: Case report and literature review / Aneurisma do tronco da artéria coronária esquerda e insuficiência aórtica de origem sifilítico: Relato de caso e revisão da literatura

Los aneurismas de las arterias coronarias son muy raros. Ocurren más frecuentemente en la arteria coronaria derecha, seguidos por los de la arteria coronaria descendente anterior y circunfleja. Los aneurismas del tronco de la arteria coronaria izquierda son aún más raros. La enfermedad más frecuentemente asociada a esta entidad es la aterosclerosis coronaria con estenosis severas en las zonas adyacentes a los mismos. La sífilis terciaria con manifestaciones cardiovasculares puede producir aortitis, insuficiencia aórtica, miocarditis y aneurismas o estenosis de las coronarias. El estándar de oro para el diagnóstico de los aneurismas coronarios es la angiografía coronaria y su tratamiento dependerá de la etiología y localización de los mismos. El tratamiento antibiótico en sífilis terciaria es imperativo; sin embargo no existe consenso en cuanto al tratamiento de los aneurismas coronarios en ausencia de obstrucciones. El tratamiento a largo plazo con anticoagulantes orales puede estar recomendado en este tipo de pacientes.

Aneurysms of the coronary arteries are very rare. Occur more frequently in the right coronary artery, followed by those of the left anterior descending coronary artery and circumflex. Aneurysms of the left main coronary artery are even more rare. The disease most often associated with this pathology is coronary atherosclerosis with severe stenosis in the section adjacent to them. Tertiary syphilis with cardiovascular manifestations can produce aortitis, aortic insufficiency, myocarditis and aneurysms or coronary stenosis. The gold standard for diagnosis of coronary aneurysms is coronary angiography and treatment depends on the etiology and location thereof. Antibiotic treatment in tertiary syphilis is imperative; however there is no consensus on the treatment of coronary aneurysms in the absence of obstructions. The long-term treatment with oral anticoagulants may be recommended in these patients.

Os aneurismas das artérias coronárias são muito raros. Ocorrem com mais frequência na artéria coronária direita, seguido por aqueles da artéria coronária descendente anterior e circunflexa. Os aneurismas do tronco da artéria coronária esquerda são ainda mais raros. A doença mais frequentemente associado com esta entidade é a aterosclerose coronária com estenose grave nas áreas adjacentes aos mesmos. A sífilis terciária com manifestações cardiovasculares pode produzir aortite, insuficiência aórtica, miocardite e aneurismas ou estenose coronária. O padrão ouro para o diagnóstico de aneurismas coronários é a angiografia coronária e tratamento depende da etiologia e localização dos mesmos. O tratamento com antibióticos na sífilis terciária é imperativo; no entanto, não existe consenso sobre o tratamento de aneurismas coronários em ausência de obstruções. O tratamento prolongado com anticoagulantes orais pode ser recomendado nestes pacientes.

Syphilitic aortitis: Rearing of the ugly head.

Context: Syphilitic aortitis has been relegated to the category of rare cardiovascular disease or a "medical curiosity" in the west. The same situation may not exist in developing countries due to the stigmata that continue to remain attached to sexually-transmitted diseases in general. Aims: To study the prevalence of syphilitic aortitis among autopsied non-atherosclerotic aortic diseases encountered in a span of 15 years. Settings and Design: Retrospective, autopsy-based study. Materials and Methods: Among 187 cases of non-atherosclerotic diseases of the aorta, 44 had been diagnosed as syphilitic aortitis on the basis of the pathological features and serology. The demographic details and modes of clinical presentation were retrieved from the health records. Depending on the presence of complicating lesions, the cases were classified as uncomplicated or complicated aortitis. Results: The 44 cases of syphilitic aortitis formed 23.5 % of the non-atherosclerotic aortic diseases. They were predominantly seen in males in the fifth decade, who often presented with valvular regurgitation, aneurysmal disease or myocardial ischemia; 13.6 % of patients were asymptomatic. Blood VDRL results were available in 19 patients; 84.2 % were positive. Concomitant involvement of the ascending, transverse and descending thoracic was seen in 45.5 % of cases. None had uncomplicated aortitis. Complications in the form of aortic regurgitation (72.7 %), coronary ostial stenosis (59 %) and aneurysms (59 %) frequently coexisted. Thirty-five aneurysms were present in 59 %, chiefly involving the aorta. Conclusions: We found syphilitic aortitis to be a common cause of aortitis at autopsy. Diagnosis should be made with the help of characteristic pathological features correlated to the clinical context and appropriate serological tests.