This 59 year old man presented with a story of shortness of breath and swelling of the legs for 7 months. Three years previously, following a bout of pneumonia, the patient had been told by his doctor that he had a "leaking valve" in the heart. Examination revealed a pulse rate of 66, collapsing in character, B.P. 184/32, and a jugular pulsation to the angle of the mandible. Right and left basal pleural effusions were present. The apex beat was in the 5th left inter-costal space, 12.5 cm. from the mid-sternal line, and there was a systolic thrill present. A to-and-fro murmur was heard in the aortic area and capillary pulsation could be observed in the ear lobes. There was also hepatomegaly and shifting dullness in the abdomen. Legs, scrotum and penis were oedematous. In the ward his cardiac failure was treated and he was given morphine for recurrent crushing chest pain. The pleural effusions were aspirated. Wassermann reaction was strongly positive. Despite treatment the patient died.
The heart has been opened to display the left ventricle, mitral and aortic valves and proximal aorta. The left ventricular wall is hypertrophied. The ascending aorta is dilated and the intima shows severe atherosclerosis, focal scarring and irregular pearly-white areas. There is narrowing of the coronary ostia. Note also the deformation of the aortic valve cusps due to destruction of the elastica by the disease process. This is a syphilitic aortitis with early aneurism formation.
Syphilitic aortitis is usually associated with aortic incompetence due to dilatation of the aortic valve ring. Damage to the thoracic aorta is a late complication of tertiary syphilis. The condition is known as syphilitic mesaortitis. It is associated with periarteritis and endarteritis of the vasa vasorum, leading to irregular scarring of the media with loss of muscle and elastic tissue. These changes result in weakening of the wall of the aorta and aneurism formation, usually involving the ascending aorta and aortic arch. The characteristic changes in the intima of the aorta are known as a tree-bark appearance. There is patchy wrinkling and thickening due to irregular scarring and fibrosis. These changes are often associated with superimposed atheroma.