|Year : 2014 | Volume
| Issue : 2 | Page : 130-132
Pulsatile chest wall mass - A trap for the unwary
Subramanian Senthilkumaran1, Shah Sweni2, Ramachandran Meenakshisundaram3, Ponniah Thirumalaikolundusubramanian3
1 Department of Emergency and Critical Care, Sri Gokulam Hospitals and Research Institute, Salem, India
2 Department of Emergency and Critical Care, Sri Gokulam Hospitals and Research Institute, Salem; Department of Internal Medicine, Chennai Medical College Hospital and Research Center, Irungalur, Trichy, Tamil Nadu, India
3 Department of Internal Medicine, Chennai Medical College Hospital and Research Center, Irungalur, Trichy, Tamil Nadu, India
|Date of Web Publication||3-Oct-2014|
Department of Emergency and Critical Care, Sri Gokulam Hospitals and Research Institute, Salem - 636 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Syphilis is less commonly seen in clinical practice. Hence, presenting features of primary, secondary, and tertiary forms of syphilis are not recalled during discussion. A case of syphilitic aneurysm observed in a 54-year-old male is presented to create awareness of this condition among healthcare professionals and stress importance of this entity in the differential diagnosis and treatment of mass in the chest wall.
Keywords: Aneurysm, aortogram, pulsatile chest wall mass, syphilis
|How to cite this article:|
Senthilkumaran S, Sweni S, Meenakshisundaram R, Thirumalaikolundusubramanian P. Pulsatile chest wall mass - A trap for the unwary. Nig J Cardiol 2014;11:130-2
|How to cite this URL:|
Senthilkumaran S, Sweni S, Meenakshisundaram R, Thirumalaikolundusubramanian P. Pulsatile chest wall mass - A trap for the unwary. Nig J Cardiol [serial online] 2014 [cited 2019 May 19];11:130-2. Available from: http://www.nigjcardiol.org/text.asp?2014/11/2/130/142119
| Introduction|| |
Syphilis, a sexually-transmitted disease caused by the spirochete Treponema pallidum continues to affect both developed and developing world. World Health Organization in 2008 estimated it to be 10.6 million new cases per year.  Primary and secondary lesions resolve even without treatment, and the infection enters a "latent" stage; it may also progress, resulting in tertiary manifestations including neurosyphilis, cardiovascular diseases, and gumma. 
Herein, we present a case of 57-year-old male, presenting with pulsatile chest wall mass as the only manifestation of tertiary syphilis in order to increase awareness and stress, the importance of this entity amongst healthcare professionals on rare presentations of less common disease.
| Case report|| |
A 57-year-old normotensive and euglycemic male truck driver presented to primary care physician with a complaint of swelling on the right upper part of anterior chest. The patient was referred to our tertiary care center for incision and drainage of the swelling-presumably an abscess. On presentation to us, we confirmed the same complaint; the swelling was insidious in onset and progressively increased in size over a period of 4 months. It was associated with a continuous, dull-aching chest pain of moderate intensity. There was no history of fever, weight loss, anorexia, neck pain, or any concurrent medications or herbal agents. Systemic examination was essentially normal with stable hemodynamics without features of heart failure or valvular heart disease. Local examination revealed an 8 × 6 cm mass on the right anterior chest wall besides the sternum. It was painful, pulsatile, non-reducible, fixed hemispherical swelling with mild hypopigmentation on the overlying skin, without any evidence of local inflammation or compression of surrounding structures [Figure 1]. Transillumination test was negative and there was no impulse on coughing.
|Figure 1: An 8 × 6 cm pulsatile mass of on the right anterior chest wall besides the sternum|
Click here to view
His hematological, metabolic profile, and electrocardiogram (ECG) were within normal limits. Posteroanterior chest X-ray revealed a widened mediastinum of 10.3 cm with a mediastinal/chest width ratio of 0.49. Cardiac silhouette, pulmonary vascularity, and lung fields appeared normal [Figure 2]. His Mantoux test and human immunodeficiency virus (HIV) screening were negative. Transthoracic echocardiography revealed normal left ventricular function and dimensions with a dilated ascending aorta with a root diameter of 5.2 cm at the sinotubular junction. The aortic valve was normal without any regurgitation. On further questioning, patient gave history of contact with multiple sexual partners as a teenager with a diagnosis of primary syphilis 35 years ago, for which he was not compliant with treatment.
Tertiary syphilis was suspected, on the basis of previous history of sexual promiscuity which was confirmed with a reactive rapid plasma regain (RPR) (1:64) along with a positive fluorescent treponemal antibody adsorption (FTA-ABS) test (1:800). Cardiac catheterization demonstrated normal coronary artery anatomy with normal pulmonary artery (PA) pressure. He had no other neurological or dermatological manifestations of tertiary syphilis. An aortogram revealed a massive fusiform ascending aortic aneurysm measuring 8.8 cm (88 mm) of maximum diameter from the origin of the brachiocephalic artery with normal diameter across the descending thoracic and abdominal aorta and no flow-limiting obstruction [Figure 3], which is the classical site for syphilitic lesion. He was treated with penicillin and probenecid for 2 weeks. The size and etiology of the aneurysm warrants surgical management, but the patient refused surgical procedure and biopsy of the lesion. On summary, we have confirmed the diagnosis as tertiary syphilis induced aortic aneurysm based on untreated primary syphilis, serology titer, and classic site of the lesion.
|Figure 3: An aortogram showing a massive fusiform ascending aortic aneurysm|
Click here to view
| Discussion|| |
Tertiary cardiovascular syphilis usually manifests with a latency of 10-40 years after the initial insult. ,, The spirochete invade the aortic wall, causing an inflammation 'aortitis' - endarteritis obliterans resulting in necrosis of elastic and connective tissue of tunica media. , The scarred and weakened aortic wall, thereby progresses into vascular complications. Aortic aneurysm is the most common complication and usually affects the tubular portion of ascending aorta (50%) (due to tropism of T. pallidum to the rich lymphatic system). Followed in descending order by aortic arch (35%), descending aorta (15%), and abdominal aorta rarely.  Severe complications like valvular disease and myocardial ischemia are more common in Indian population.  Most common initial symptom is chest pain due to aneurysmal dilatation,  however, other symptoms like angina, dyspnea, and rupture occur frequently depends on the site and extent of the lesion.
Serologically,  Treponema-specific tests like FTA-ABS are more specific compared to RPR or Venereal Disease Research laboratory (VDRL) tests. Consensus statement  advises surgical repair of any ascending aorta of aortic root aneurysms greater than 5.5 cm in diameter. Even after explaining the risks involved and counseling, the patient did not want to undergo surgical repair. Long-acting penicillin for 2 weeks is the recommended treatment in tertiary syphilis.  Practicing doctor has to realize and explain the patient and family members on the progress of the disease despite antibiotic treatment, and the need for long-term follow-up.
| Conclusion|| |
This case of syphilitic aneurysm is presented not only to create awareness of rare presentations of less common disease among healthcare professionals. Also, this case highlights on the importance of never needling/draining/excising a mass without the essential investigations including imaging studies even if it looks like an 'abscess'.  Aneurysms of ascending aorta may present insidiously with very few signs and symptoms. Health policy makers have to utilize the media well to create awareness among high-risk group on the importance of barrier methods and the need for completing the treatment for early lesions.
| References|| |
|1.||Rowley J, Toskin I, Ndowa F. Global incidence and prevalence of selected curable sexually transmitted infections. Geneva: World Health Organization; 2012. Available at:http://www.who.int/reproductivehealth/publications/rtis/2008_STI_estimates.pdf [Last accessed on 2014 Mar 05]. |
|2.||Hook EW 3 rd , Peeling RW. Syphilis control--A continuing challenge. N Engl J Med 2004;351:122-4. |
|3.||Chockalingam A, Gnanavelu G, Alagesan R. Massive aortic aneurysm presenting as chest wall swelling. Heart 2004;90:292. |
|4.||Bappu NJ, Chakraborty B, Bisoi A, Subramaniam G, Chauhan S, Venugopal P, et al. A massive pulsatile chest wall mass. N Z Med J 2006;119:U1852. |
|5.||Roberts WC, Ko JM, Vowels TJ. Natural history of syphilitic aortitis. Am J Cardiol 2009;104:1578-87. |
|6.||Vaideeswar P. Syphilitic aortitis: Rearing of the ugly head. Indian J Pathol Microbiol 2010;53:624-7. |
|7.||Larsen SA, Steiner BM, Rudolph AH. Laboratory diagnosis and interpretation of tests for syphilis. Clin Microbiol Rev 1995;8:1-21. |
|8.||Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266-369. |
[Figure 1], [Figure 2], [Figure 3]