Case Presentation: An elderly male with history of hypertension and significant hearing impairment presented for the evaluation of progressive dyspnea on exertion. Patient had been experiencing dyspnea for a few months and family had noticed patient’s lips turning cyanotic on occasion. Admission vitals: temperature 100.8 degrees, BP 121/64, HR 96, RR 20, O2 sat 95% on room air. Exam remarkable for significant hearing deficit; heart and lungs were benign. Labs showed WBC count 2.9×10^9/L (range 3.8 – 10.6), hemoglobin 8g/dL (range 12.9-16.9). Baseline not available. Chest x-ray was unremarkable. Non-contrast CT chest showed unremarkable lungs. It showed an 8mm outpouching at the level of distal descending aorta suggestive of a penetrating aortic ulcer. Echocardiogram showed a preserved left ventricular function, and normal aortic root and valve. Infectious disease and vascular surgery were consulted. Given fever, hearing loss and aortic ulcer, syphilis screening was done. Serum RPR was positive (titer 1:16) with reflex FTA antibodies also positive. HIV screen was negative. Patient denied any history of syphilis. Regardless, a working diagnosis of late syphilis vs neurosyphilis was made and patient underwent a lumbar puncture. CSF analysis was negative for VDRL. Despite negative VDRL, decision was made to treat as neurosyphilis given significant hearing loss. Patient was treated with penicillin G (18 million U) IV continuous infusion for 14 days. Vascular surgery recommended follow up with non-contrast CT chest in a few months to ensure stability of the lesion.

Discussion: Syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum. This organism is known for its ability to evade the immune system and invade tissues which produces the symptoms of this disease. First known reported cases of syphilis date back to the 1400s and its presence in the human society for hundreds of years has allowed scientists to identify multiple stages of untreated disease. Primary syphilis is infection of < 1-year duration which presents as painless genital ulcer(s). Secondary syphilis manifests 6-8 weeks after the resolution of primary symptoms and presents as fever and a widespread maculopapular rash. Patient enters the latent stage when the symptoms of secondary stage subside. Tertiary syphilis presents 3-15 years after original infection and presents with neurological or cardiac involvement (1).Cardiovascular syphilis usually presents 10-30 years after the initial infection (2). It causes obliterative endarteritis of vasa vasorum which leads to weakening of tunica media and resultant characteristic aneurysmal dilatation of the aorta. The lesions usually involve the aortic root and ascending aorta leading to aortic valve insufficiency and stenosis of coronary ostia (2). Our patient’s presentation was unusual and involved small outpouching of distal thoracic aorta. There is significant mortality associated with cardiovascular syphilis with the 1-year mortality rate approaching 80% in untreated disease (3). Per CDC data, the incidence of syphilis has been steadily rising since 2001 and the year 2018 has seen a 71.4% increase in the number of reported cases compared to 2014. This rise in the numbers should be a reminder to physicians to not dismiss this differential as obsolete.

Conclusions: Given the resurgence of this disease it is incredibly important to keep unusual presentations of late disease in differential as untreated disease carries high mortality.