Case Presentation: Syphilis manifestations are widespread, varying with stage and type of visceral involvement. Our detailed understanding of its natural history comes from the pre-antibiotic era and sources like the Tuskegee study. Herein we present a case of complete heart block in a patient with aortic dilation who was subsequently diagnosed to have neurosyphilis during the admission, potentially tying up his extremely varied clinical manifestations. A 74-year-old male with a history of hypertension and ascending aortic aneurysm presented to the cardiac ICU with complete heart block, needing emergent placement of a transvenous pacemaker, and eventual implantation of a permanent pacemaker. While reviewing records, it was found that he had developed significant personality changes as reported by his daughter, including disinhibited behavior, and cognitive deficits in the past ten months, along with worsening hearing loss needing evaluation for hearing aids approximately four months ago. His neurological manifestations had been worked up extensively with imaging and labs, with no cause established. Interestingly, among labs that were sent on admission, he had an RPR titer of 1:64; further interview revealed six sexual partners in the past year with inconsistent use of barrier contraception. Eventually, CSF VDRL was 1:8, consistent with neurosyphilis, and he was treated with penicillin G for 2 weeks. A repeat CT showed mild dilation of the ascending aortic aneurysm at 4.7cm, up from 4.1cm two years ago, detected incidentally and thus far asymptomatic. No other cause for his initial complete heart block was established by discharge.
Discussion: Neurosyphilis is classically thought to be a late manifestation of the disease, although in reality can occur at any stage. While it typically presents as tabes dorsalis, general paresis, symptomatic meningitis, there is a spectrum also described as atypical neurosyphilis, which encompasses acute onset neurocognitive deficits, and other features that do not fit into the classic picture. Otologic syphilis is a well-described form of neurosyphilis even without other features. Cardiovascular manifestations are typically tertiary, most often presenting as aortitis. Per an autopsy-based study of 100 cases of syphilitic aortitis, manifestations included uncomplicated dilation, aortic insufficiency, aneurysm, and ostial stenosis. Complete heart blocks secondary to syphilitic gumma have been described only in case reports on literature review. While the etiology of his complete heart block was never established, the overall picture is a rare one and could be tied together with single disease diagnosis.
Conclusions: Syphilis is known as the great mimic for good reason. With its incidence on the rise, it is imperative that our clinical suspicion remains high even in those cases that are not textbook syphilis ones.