(177) "A Thrombus You Don’t Want to Syphil-Miss": A Case of Aortic Thrombus as a Result of Syphilis

Introduction: Syphilis is a sexually transmitted infection that presents with a wide array of symptoms. Due to the advancement of antibiotics, tertiary syphilis is rare. We present a case of a woman who came in with body aches and abdominal pain due to an aortic thrombus. Would you think Syphilis?

Description: Patient is a 38-year-old woman who came in with worsening aches affecting her whole body for months. Symptoms included constant, non-radiating RUQ abdominal pain with nausea for the last 10 days. She also reported severe weakness and fatigue for 4 months and has been wheelchair-bound. Vitals noted HR 120, BP 99/68, and O2 sats 95% on room air. Labs noted Hgb 11, target cells, CO2 32, AGAP 18, lactic 6, Mg 1.3, troponin negative, and ethanol level 107. MRI spine was unremarkable. CTA chest was negative for aortic dissection or PE. CT abdomen with contrast showed a 2.7cm x 1cm infrarenal aortic thrombus extending to the IMA causing 90% stenosis of the aorta with a left renal vein thrombosis. Vascular surgery was consulted and started her on a heparin drip. A hypercoagulable panel including homocysteine, Factor II, Factor V Leiden, Fibrinogen, Lupus, Protein C and S were all negative. Autoimmune workup, COVID and RPR were all negative too. Interestingly, FTA antibody (FTA-ABS) came back positive. Vascular team decided that medical management with warfarin would be the most appropriate. She improved and was discharged to acute rehab.

Discussion: 25-40% of patients with untreated syphilis develop tertiary syphilis which may appear up to 30 years after primary infection. The most common manifestations are cardiovascular syphilis (aortitis), gummatous syphilis (granulomatous, nodular lesions in organs), and CNS involvement (general paresis and tabes dorsalis). Cardiovascular syphilis involves the ascending thoracic aorta and is thought to be due to vasculitis in the vasa vasorum leading to weakening of the wall. Syphilis may also involve the coronary arteries, resulting in narrowing and thrombosis. Treponemal tests, such as FTA-ABS, are more complex and expensive to perform and thus have traditionally been used as confirmatory tests. We would like to make practitioners aware that patients with tertiary syphilis, could have aortic thrombosis without any signs of ischemia and are at risk for infarction.