A 34 y.o. woman comes to the ED with abdominal pain she was found on the floor in her basement.

The pt also has a hx of syphilis, HIV, and schizophrenia.

A non con scan of the abdomen shows a large L perirenal hematoma

Hint : the pt has a vascular abnormality

Our patient had syphilitic aortitis with known syphilis in the past and acute rupture. Syphilitic aortitis usually occurs with tertiary syphilis. It  begins as inflammation of the outermost layer of the blood vessel, then the vasa vasorum becomes hyperplastic causing restriction of blood flow and ischemia of the outer 2/3 of the aortic wall.  Smooth muscle and elastic fibers disappear and an aneurysm develops. There is danger of rupture as the size increases.   Syphilis is diagnosed with a treponemal test (which is always positive once the pt has had syphilis, the FTA) and a non treponemal test(the VDRL), which is used to follow the disease since it will increase about four fold in acute infection and decrease about the same amount with treatment.  Interestingly, in large studies  some patients with presumed syphilitic aortitis on autopsy do not have positive tests but In general, the VDRL is 78-86% sensitive for detecting primary syphilis, 100% sensitive for secondary syphilis and 95-98% sensitive for detecting tertiary syphilis.

Several other inflammatory  processes involve large vessels.  These include tuberculosis, mycotic aneursyms, and even HIV.  Rheumatoid arthritis, polyarteritis nodosa and lupus can all cause aneursyms. In rare cases, Kawaski disease can cause a panvasculitis as well.

syphilitic aortitis can occur without an aneursym as in the case above.

Syphilitic aortitis is found 90% of the time in the ascending aorta and 10% of the time in the descending aorta as in this case. Our patient was taken directly to the OR where she arrested on transfer to the operating table.  CPR was initiated and the abdomen was opened but dense adhesions( presumably from previous PID)  prevented placement of a proximal clamp. The physician had to bluntly dissect to the supraceliac aorta.  She regained a BP of 70 but then went into v tach then PEA. The code was called and the pt expired.

Stone J, Breneval P, Angelini A et al. consensus statement on surgical pathology of the aorta from Society of Cardiovasc Patholoy and Association for European Cardiovascular Pathology(review)24(5):267-78. Doi 10.1016/j.carpath 2015. 05.001

Roberts W, Ko J, Travis J. Natural history of sypilitis aortitis. Doi 10.1016/j.amcaard.2009.07.031

White R. comments about the Tuskeegee Study of Untreated Syphilis. Am J Card.2010July 15;106(2):293.doi:10.1016/j.amjcard04.003

Roberts W, Bose R, Ko J et al. Identifying cardiovascular syphilis at operation. Am J of Card 2009 Dec 1;104(11)1588-94

DelRe F, Falcetta G, Pratali S, et al. syphilitic aortitic aneurysm in the third millennium. Aorta 2018 Oct: 6(5)118-119.