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Syphilitic Angina

  • Henry Chu
    Affiliations
    Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles
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  • Diana Arsene
    Affiliations
    Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles
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  • Grace Huang
    Affiliations
    Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles
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  • Farhood Saremi
    Affiliations
    Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles
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  • Shahbudin H. Rahimtoola
    Correspondence
    Requests for reprints should be addressed to Shahbudin H. Rahimtoola, MD, LAC USC Medical Center, Old GNH Room 3221, Los Angeles, CA 90033.
    Affiliations
    Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles
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      To the Editor:
      A 49-year-old man from El Salvador presented with classic angina. He had no risk factors for atherosclerosis. Electrocardiogram demonstrated 2-mm ST depression in leads II and III, and augmented voltage left foot lead (AVF); troponins were elevated. The chest radiograph showed normal heart size and aorta. Echocardiogram showed hypokinesis of the inferior wall with very mild aortic regurgitation. Coronary angiography showed severe narrowing of the proximal 10 mm of the right coronary artery (Figure 1). Beyond that, the right coronary artery and the left coronary artery were normal. Reconstructed computed tomographic imaging showed a normal-sized ascending aorta and severe narrowing of the proximal right coronary artery (Figure 2). The patient was treated for syphilis because of his history of unprotected sex and ulcer on his penis years earlier, and had a rapid plasma reagin titer of 1:32.
      Figure thumbnail gr1
      Figure 1Coronary arteriogram showing narrowing of the ostium and that of the proximal 10 mm of the right coronary artery.
      Figure thumbnail gr2
      Figure 2Reconstruction of contrast-enhanced multislice computed tomography scan of the heart. The arrow points to the narrowing of the proximal portion of the right coronary artery and its ostia. Note that there is no dilatation of the ascending aorta and of the aortic root.
      Tertiary syphilis affecting the aorta is primarily an arteritis of the vasa vasorum,
      • Roberts C.R.
      • Ko J.M.
      • Vowels T.J.
      Natural history of syphilitic aortitis.
      which may lead to formation of a saccular aneurysm; it may extend down into the annulus, resulting in severe aortic regurgitation. Fibrosis of the media may result in thickening of the aortic wall and prevention of aortic wall dilatation. The fibrosis can extend beyond the ascending aorta to involve the proximal portion of the coronary arteries, the arch, and the branches of the arch of the aorta, which this patient demonstrated. Routine anti-anginal treatment provided modest relief. Our goal was to extend the studies of the arch to evaluate the innominate artery and the proximal portion of the subclavian artery. If the subclavian and the origin of the right internal mammary artery were unaffected, the goal was to implant the right internal mammary artery to the right coronary artery beyond the narrowing. The patient wanted to defer additional testing and possible surgery to a time in the future.

      Reference

        • Roberts C.R.
        • Ko J.M.
        • Vowels T.J.
        Natural history of syphilitic aortitis.
        Am J Cardiol. 2009; 104: 1578-1587