From the Guidelines
Syphilis can involve the cardiovascular system, particularly in tertiary syphilis, which typically develops 10-30 years after initial infection if left untreated, and can lead to serious complications such as aortic aneurysm, aortic regurgitation, and coronary ostial stenosis. The relationship between syphilis and cardiac involvement is well-established, with cardiovascular syphilis primarily manifesting as syphilitic aortitis, which can cause significant morbidity and mortality if not treated promptly and effectively 1.
Pathophysiology and Clinical Manifestations
The pathophysiology involves T. pallidum spirochetes invading the vasa vasorum of the aorta, causing endarteritis, medial necrosis, and scarring that weakens the aortic wall, predominantly affecting the ascending aorta and aortic arch, sparing the descending aorta 1. This process can lead to aortic aneurysm, aortic regurgitation, and coronary ostial stenosis, which are potentially life-threatening complications.
Diagnosis and Treatment
Treatment for cardiovascular syphilis requires benzathine penicillin G 2.4 million units intramuscularly once weekly for three consecutive weeks, and for patients with penicillin allergy, doxycycline 100 mg orally twice daily for 28 days can be used, though desensitization to penicillin is preferred when possible 1. Patients with cardiovascular syphilis should undergo baseline echocardiography and possibly CT angiography to assess aortic involvement, and regular cardiac follow-up is essential as the structural damage to the aorta may be irreversible despite antibiotic treatment, and some patients may require surgical intervention for aortic valve replacement or aneurysm repair.
Importance of Early Detection and Treatment
Early detection and treatment of syphilis is crucial to prevent these potentially life-threatening cardiovascular complications, and it is essential to prioritize the treatment of syphilis to prevent the development of tertiary syphilis and its associated cardiovascular complications 1. Regular screening for syphilis, particularly in high-risk populations, can help identify cases early and prevent long-term complications.
Key Considerations
- Cardiovascular syphilis is a serious complication of untreated syphilis
- Early detection and treatment are crucial to prevent long-term complications
- Benzathine penicillin G is the preferred treatment for cardiovascular syphilis
- Patients with penicillin allergy can be treated with doxycycline
- Regular cardiac follow-up is essential to monitor for potential complications.
From the Research
Relationship Between Syphilis and Cardiac Involvement
The relationship between syphilis and cardiac involvement is a significant one, with syphilis often manifesting in the cardiovascular system in its advanced stages. Some of the key cardiac involvements associated with syphilis include:
- Simple aortitis
- Aortic valve insufficiency
- Coronary artery stenosis or obstruction
- Aortic aneurysm
- Mucinous myocarditis 2, 3, 4
Cardiovascular Manifestations of Syphilis
The cardiovascular manifestations of syphilis can increase morbidity and mortality in the tertiary stage of the disease. These manifestations include:
- Syphilitic aortitis
- Aortic aneurysm
- Aortic regurgitation
- Coronary artery involvement
- Acute myocardial infarction
- Heart failure
- Atrial fibrillation
- Ischemic stroke
- Hemorrhagic stroke
- Venous thromboembolism
- Cardiovascular death 4
Diagnosis and Treatment of Cardiovascular Syphilis
The diagnosis of cardiovascular syphilis requires a thorough understanding of the clinical presentations of the disease, including asymptomatic varieties. Treatment typically involves the use of penicillin, doxycycline, and other antibiotics, as well as consideration of surgical intervention for complications such as aortic aneurysm or coronary stenosis 3, 5, 6
Importance of Early Treatment
Early treatment of syphilis is crucial in preventing the progression of the disease to its tertiary stage, where cardiac involvement is more likely to occur. A single dose of 2.4 million units of benzathine penicillin G remains the drug of choice for managing early syphilis, and enhanced antibiotic therapy has not been shown to improve treatment outcomes 5