Cardiovascular Syphilis and Late Benign (Gummatous) Syphilis

00:01 And then we have cardiovascular syphilis, which occurs in maybe 10 percent of all patients who have had syphilis, and it’s the vasa vasorum – the blood vessels that supply blood to the wall of the aorta.

00:23 And because the circulation to the wall of the aorta is compromised, you get an aortitis with dilation and calcification of the aorta.

00:36 The aortic valve annulus can weaken and the cusps of the valve can be destroyed and cause aortic regurgitation.

00:51 So let’s talk about aortic regurgitation just as an aside here.

00:58 It’s one of the most fascinating types of murmurs that a physician can encounter.

01:05 So first of all, the aortic valve doesn’t work, and so the heart contracts forcefully, blood goes out of the aorta.

01:16 But because the valve doesn’t work, it rushes back into the ventricle and makes a noise that is of a decrescendo nature.

01:25 If the murmur sounds like this, it’s kind of [making sound].

01:31 It’s a decrescendo murmur happening in diastole and you hear it all along the left sternal border.

01:40 But because so much blood is falling back into the ventricle, that means the heart more forcefully ejects that load of blood and it may cause some fascinating physical findings.

01:56 For example, they may have the sign of de Musset.

02:01 The forceful systole makes the head bob with each systole.

02:08 Of course, you have to pay attention to the patient to notice something like that.

02:15 You may also pick it up when you examine the oropharynx.

02:19 If you look at the uvula during each systole, the uvula may turn red.

02:27 And because all of the blood fell back into the ventricle, it may turn white during diastole, so alternate blanching and suffusion of the uvula.

02:38 Now if you take your fingers and push down lightly on the nail, you’ll find that the nailbed turns white.

02:46 That’s because you’ve turned off the circulation.

02:49 But if you do that with somebody that has aortic regurgitation and you look at the nailbeds, you will find that during systole, instead of staying white, it turns red with each systole, so called Quincke’s pulse.

03:10 If you look at the pupils of the patient carefully in somebody who has aortic regurgitation, what you may find is alternate constriction and dilation of the pupils – constriction occurring with each systole and dilation occurring during diastole.

03:33 That’s because of the stimulation of this forceful ejection at the carotid bodies, which turns on the parasympathetics causing constriction and relaxes during diastole causing dilation of the pupils.

03:52 Also, if you take the stethoscope and place it over the femoral artery and press, you will create a murmur in a normal person that sorts of sounds like this [making sound].

04:08 But in somebody with aortic regurgitation, as all the blood falls back into the ventricle, you may get a two and fro murmur [making sound] over the femoral artery.

04:21 These are just interesting physical findings, but may make you listen carefully at the heart for aortic regurgitation, or take a careful cardiovascular history.

04:34 The least common complication is actually that of an aortic aneurysm.

04:41 And I think you can see here in the panel shown how this patient has a widened mediastinum, which shows you that the aorta is actually widened.

04:52 This occurs in 5 to 10 percent of patients who have syphilitic aortitis.

05:03 Then another form of tertiary syphilis is what we call late benign syphilis, or gummatous syphilis.

05:12 You can have a gumma, which is essentially a granuloma, in any organ.

05:18 But it usually involves the skin and produces some kind of a nodule, which turns out to be punched out and often with a rugged ulcer.

05:30 It can be on mucocutaneous surfaces.

05:33 It can be in the skeletal system and cause actually fracture of bones or joint destruction.

05:39 And it can be just an isolated gumma or multiple.

05:44 And they can be very variable in size from small defects to large tumor-like masses.

05:53 You can have a gumma in the liver and those patients will often have fever, epigastric pain, and tenderness in the right upper quadrant.

06:03 They may even have cirrhosis.

06:06 You can have a GI tract gumma with an ulcer or something that actually looks like adenocarcinoma of the colon.

06:15 You can have upper respiratory tract gumma, and the classic example would be perforation of the nasal septum, or perforation of the hard palate.

06:27 Any finding like that, you should suspect tertiary syphilis.