053 Infective aortitis

Abstract

Background: A 57 year old Somali male presented to urology with right testicular and abdominal pain. There had been weight loss but no other systemic features. He had a history of psoriasis 10 years previous treated with UV therapy. He smokes seven cigarettes a day, does not consume alcohol and regularly runs 15km. Methods: He appeared well on examination with BP 181/91, 4+ blood on urine dip. He had scars from his previous rash over his trunk and limbs with some active scaly raised rash on his lower legs. Neurological examination showed absent ankle jerks but physical examination was otherwise unremarkable. Blood tests revealed a CRP of 99 with Hb 125, normal white cell, platelet count, liver function and eGFR 74. Ultrasound of his testes showed a right inguinal-scrotal hernia with normal testes. Abdominal ultrasound revealed bilateral hydronephrosis. He went on to have a CT scan which showed a soft tissue mass inferior to the origin of the renal arteries with early obstruction of the IVC and confirmed bilateral hydronephrosis. Chest X ray was normal. Biopsy was discussed but the mass was felt to arise from the abdominal aorta vessel wall therefore was not possible. ANA, ANCA, complement and immunoglobulins were all normal. HIV, hepatitis and TB screen were also negative. Results: Further serology including syphilis serology was sent and came back with positive TPPA and EIA, with negative IgM and Rapid Plasma Reagin. Results were felt to be consistent with late latent syphilis, likely to be responsible for the aortitis. He was started on oral prednisolone and also received 3 x benzathine penicillin im injections (once a week for three weeks). His CRP responded within two weeks to 10 and repeat ultrasound after six weeks of steroid treatment showed improvement in his hydronephrosis. Conclusion: Syphilis is caused by treponema palladium and is spread via infected lesions (usually sexual contact) or vertically in pregnancy via the placenta. Infection spreads to regional lymph nodes with subsequent dissemination. Weeks to months later secondary syphilis develops which can affect multiple systems usually with constitutional symptoms and often a rash. This typically resolves in 3-12 weeks without treatment. It is possible that the 'psoriasis' several years ago was a manifestation of secondary syphilis in this male. The latent phase of syphilis is variable with late or tertiary syphilis occurring in approximately 1/3 of untreated patients. Cardiovascular manifestations can include aortitis but this usually affects the ascending/thoracic aorta. Other manifestations include Gummatous disease. Gammas are granulomatous lesions that can occur anywhere but commonly in skin, bone. They can be visceral and present as a mass lesion which is also a possibility here. This case is an unusual presentation of late syphilis.