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                              A52.02 Syphilitic aortitis

Syphilitic aortitis is inflammation of the aorta associated with the tertiary stage of syphilis infection. SA begins as inflammation of the outermost layer of the blood vessel, including the blood vessels that supply the aorta itself with blood, the vasa vasorum.

Aortitis is one of the many possibilities of lesion caused by tertiary syphilis. Between all the cardiovascular lesions, the aorta's injury is the most common. We report a case of a 48-year-old patient diagnosed with syphilitic aortitis who had undergone surgery for the replacement of the aortic root and aortic valve. The diagnosis hypothesis was pondered because of the in situ aspect of the arterial damage. Although the rarity of the disease, it persists.

Syphilis is an infectious disease transmitted mainly through sexual intercourse and that can have several presentations at various stages . Tertiary syphilis, now rare due to effective antibiotic treatment already in use for several years, is responsible for cardiovascular syphilitic lesions . Among the lesions, the most common is the syphilitic aortitis. In untreated syphilis, aortitis may manifest after 10 to 40 years after the initial sexual contact . The ascending aorta is affected in 50% of the cases, followed, in descending order, the aortic arch, the descending aorta and abdominal aorta, with possible impairment of coronary ostia and aortic valve .

The main cause of death occurred in about 80% of cases, and rupture of saccular aneurysms, when not treated surgically .
After primary infection, there is the presence of Treponema pallidum in the aortic wall, initially in the adventitia and soon after in the lymphatic vessels. This is one of the main reasons for the tropism of spirochetes in relation to the ascending aorta, since it is rich in lymphatics .

The vasa vasorum undergoes a process of endarteritis obliterans, necrosis of medial layer (mesoarteritis), and infiltration of plasma cells. Consequently, the elastic tissue of the vessel is destroyed and replaced by scar tissue. The inflammatory process may continue for a long time and can be found until 25 years after initial infection .
The clinical presentation may be of angina when there is obstruction of the coronary ostia, dyspnea, when there is aortic failure. However, the most common clinical symptom is chest pain secondary to rapid expansion of the luetic aneurysm .

The primary lesion of cardiovascular syphilis is aortitis, an inflammatory response to the invasion of the aortic wall by the Treponema pallidum that evolves to obliterative endarteritis of the vasa vasorum and results in necrosis of the elastic fibres and connective tissue in the aortic media.Classically, syphilitic aneurysms occur in 90% of cases on the thoracic aorta, and in 10% in the abdominal aorta, . Infection of aortic wall develops during the secondary or bacteraemic phase of syphilis, having a latent period from infection until the clinical presentation ranging from 5 to 50 years 

 low-grade fever was diagnosed with aortitis and infective endocarditis, due to Treponema pallidum infection, using polymerase chain reaction analysis. This case suggests that syphilis might cause infective endocarditis.Rheumatic fever and scarlet fever can begin as strep throat and then leave scars on your aortic valve. The scars can cause your aortic valve to narrow.

Aortitis is histopathologic diagnosis of inflammation of the aorta,  and it is representative of a cluster of large-vessel diseases that have various or unknown etiologies. Although inflammation can occur in response to any injury, including trauma, the most common known causes are infections, immunologic, or connective tissue disorders. Infections can trigger a noninfectious vasculitis by generating immune complexes or by cross-reactivity. The etiology is important because immunosuppressive therapy, the main treatment for vasculitis, could aggravate an active infectious process.

Inflammation of the aorta can cause aortic dilation, resulting in aortic insufficiency. Additionally, it can cause fibrous thickening of the aorta and ostial stenosis of major branches, resulting in reduced or absent pulses and/or low blood pressure in the upper extremities, possibly with central hypertension due to renal artery stenosis

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