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Syphilitic aneurism of the aortic arc refers to a syphilis induced abnormal bulge of the aorta. This occurs when a weakness emanates from the wall of the thoracic arc of the aorta. The disease manifests itself during the tertiary stage of syphilis when the patient has not been treated.
Etiology of the lesion
As the name suggests, the lesion emanates from syphilis; however, the disease should be in its tertiary phase. At this point, the sections of the aorta known as the vasa vasorum and the adventitia inflame. This causes weakness of the media and the formation of an aneurysm. The aneurysm comes after the medial muscle fibres have been scarred. The lesion may manifest as a cylindrical swelling on the arc of aorta or may also occur as a saccular distension.
Macroscopic and microscopic findings
Diagnosis and evaluation of the condition aims at analysing the features (morphology) of the aorta and the structures surrounding it. It also entails examining the size and character of the aneurysm as well as the characteristics of the blood vessel.
Patients need to do a CT scan of their thoracic aorta in order to assess the thickness of their walls and detect the presence of aneurysms. The radiologist ought to examine the mean, maximum and minimum diameter of the aorta. Usually, the arch of aorta is approximately 2cm. If it is abnormally large, then a syphilitic aneurysm should be suspected. Once the aneurysm has been detected, one must determine the part of the aorta that it belongs to. If it occurs on the arch, then the condition should be further expected. The nature of the aneurysm must be studied by looking at three layers: the intima, adventitia and the media. If these three layers do not exist, then the aneurysm may be a false one.
The intima should have a nodular shape like a tree bark, and it should also look irregular for positive confirmation of the disease (Taufiek et al. 1258). The media has a high degree of vascularisation for Syphilitic aneurysms. The pathologist must also look at the relationship of the blood vessel to others as well as the effect on other structures. In this regard, one must determine whether new complications arose such as ruptures. A rupture often arises when the size of the aneurysm is quite large. Laplace’s law states that wall tension is proportional to an aorta’s diameters. Therefore, the larger the size of the aneurysm, the higher the chances of rupture. A rupture will be seen in the CT scan through a highly attenuated hematoma. Alternatively, an aneurysm that is just about to rupture may be seen as a crescent within the mural thrombus. A contained rupture may also be seen as a draped aorta.
With regard to the pathology of the aorta, a person with this condition may have scattered plasma cells as well as lymphocytes. In other words, infiltration of these cells will occur. Sometimes the cells may collect on regions that are close to blood vessels. Adventitial vessels will possess lymphocytic cuffing as well as endarteritis. The latter signs are typical of syphilis in patients. Additionally, one will find elastic fibres have been lost; fibrosis may occur here. When the fibrosis is extensive, it may involve the aortic valve and the cusps. An examination of the aorta should also show a tree-bark change of the aorta. The aorta should also be working insufficiently because of constriction or diameter changes. This manifests as reduction of blood flow.
The x-ray will show a calcified aorta on its lining. It will also demonstrate a wide aortic root. When physically examining the patient, one will hear a loud tambour of the second sound of the aorta.
Symptoms and signs
Since the condition affects the thorax, then most symptoms will involve this area. A patient will feel pain in the anterior and posterior parts of the chest. He or she will have a hoarse voice owing to the paralysis of the vocal chords or laryngeal nerve compressions. Some may find it difficult to swallow food and drinks. Most individuals may report dyspnea and coughing that emanate from compression of the trachea. Additionally a rapture of the aneurysm may occur, and this may affect the bronchus thus leading to haemoptysis. Others may report angina, which comes from lesions of the aortitis. Lastly, the disease may manifest as shock when the aneurysm ruptures and affects the pleural space. At this point, heart failure can occur and the patient will die (Kent & Romanelli 230).
Someone with Syphilitic aneurism of the aortic arch will possess unequal pulses or blood pressure of the extremities. In the third or second intercostal space, the person will have palpable pulsations of the chest wall. Additionally, one is likely to report increased cases of tracheal deviations. Patients may also show conditions of vocal chord paralysis
Patients should be given penicillin for the treatment of syphilis. After completion of the medication, the person should undergo surgical repair. In this regard, the section of the artery wall that bulges should be cut and Dacron fibre sawn on to replace the vessel wall that has been cut. The surgical option should occur after continual monitoring of the size of the aneurysm, or after observation of other symptoms. Once the aneurysm has exceeded 5.5 cm, then surgery ought to be considered. The monitoring process can start early if symptoms are not prevalent. CT scans can be done annually. The doctor ought to determine whether the rate of the growth of the aneurysm exceeds 1cm; when this occurs, then surgery is plausible. Annual growth rates of 0.07cm to 0.42cm may not warrant surgical repair. If the medical practitioner underestimates the need for surgery or when the condition has worsened tremendously, then the aneurysm could rupture. When this occurs, approximately 50% of patients die. There are also risks in performance of surgery because 1-2% of patients that undergo the procedure often die.
If the character of the blood vessels, structures and aneurysm do not warrant surgery, then the patient should be treated for syphilis. Since this condition will occur at late stages, then weekly administration of penicillin G for a period of 21 days ought to be done. The treatment will prevent further deterioration of the disease.
Relevance to dental practice
A dentist ought to alter his or her treatment plan in accordance with this condition. One should also know what to do during emergencies. When a person has the condition, the use of antibiotics should be minimised. As stated earlier, severe cases of the condition may lead to diminished blood flow, a dental surgeon may handle a patient with ischemic conditions. The person may experience intense and severe chest pains. The dentist must call for emergency service and stop the dental activity. The patient ought to be given oxygen and allowed to stabilise. If the pain refuses to subside, the dental surgeon must consider cardiopulmonary resuscitation (Munoz et al. E302).
Kent, Margaret & Francis Romanelli. “Re-examining syphilis: an update on epidemiology, clinical manifestations and management.” Annual Pharmacother 42.2 (2008): 226-236. Print
Munoz, Maria, Yolanda Soriano, Rafael Roda & Garcia Sarrion. “Cardiovascular diseases in dental practice: Practical considerations.” Med. Oral Patol Oral Cir Bucal 1.13(2008): E296-302. Web.
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Taufiek, Rajab, B. Chir, & Robert Gallegos. “Giant Syphillic Aortic Aneurysm.” The New England Journal of Medicine 364(2011): 1258. Web.