All Lues?
Mark Crislip
Back from a week off. As much as I like ID, I really like not working. Work has become like ice cream. I love ice cream and never tire of eating it. Especially with homemade hot fudge made from sweetened condensed milk. Mmmmmm. So good. But I grow a tad weary of this particular flavor.
The patient, middle-aged, has the new onset of headache and unilateral tenderness over the temporal artery. The ESR was only 75, but they went for a temporal artery biopsy. The pathologist called the read "difficult" after it showed a dissection but not the classic changes of temporal arteritis. Early disease? They wondered.
Steroids were started.
Then the patient developed visual changes that the ophthalmology found suspicious and sent off studies for syphilis and Tb and the RPR came back at 1:256.
LP refused.
Going through the old records, the patient had never been tested for syphilis in the past but had been at Outside Hospital a year prior for a complicated head and neck infection that, among other things, resulted in an eight-week course of ceftriaxone. I have to confess that I cannot think of any soft tissue infection that needs more than few days of therapy, but not all the information is at my disposal. Still, there is no way any Treponema would have survived that antibiotic onslaught. The Lues would have to have been acquired within the last year.
Or the patient had syphilis a year ago with an unmeasured very high RPR, and it has, a year later, fallen to 1:256. If that was the case, the Lues should have been eradicated by the two months of ceftriaxone and what we are seeing is temporal arteritis. Kind of different treatments, so we sent of studies looking for Treponemal DNA, and it was positive. So syphilis it is. But.
Does syphilis result in dissection of the temporal artery?
Aorta? Yes, but rare with syphilitic aneurysms, and it has a curious pathophysiology:
Syphlitic Aneurysms arise during tertiary syphilis due to chronic inflammation in the tunica adventitia of large elastic arteries, particularly the aorta. The inflammatory response to the spirochetes causes an obliterative endarteritis of the vaso vasorum, leading to a loss of blood supply to the elastic tunica media. Ischemia of the tunica media, combined with further syphilitic invasion into the tunica media itself, results in medial destruction and weakening, ultimately causing dilation and aneurysm-formation. Fibrosis of the vascular wall can give involved vessels a 'tree-bark'-like appearance and probably protects against aortic dissections which are not a consequence of syphilitic aneurysms.
Smaller vessels? There are reports of carotid artery dissection. And that's it. I can't find where syphilis has ever been associated with temporal artery dissection:
Your search - "temporal artery dissection" syphilis - did not match any articles.
Temporal artery dissection is a rare process outside of temporal arteritis, with only one spontaneous case reported.
I suspect this is all secondary syphilis with vasculitis, including the temporal artery with the first reported case of an associated dissection and involvement of the retinal arteries, but once ophthalmology says the eye is involved, it's treatment for tertiary syphilis.
But I am an Occams kind of guy who is worried this is a Hickam's case, since the diagnostics are not cut and dry. Too young and the ESR not that high with a nondiagnostic pathology for TA against the first case of syphlitic temporal artery dissection.
I do find the staging of syphilis unsatisfying. It is clear the spirochete is widely disseminated from the start of the chancre, including the CSF. That has been suspected since 1919 on the basis of LPs where
2% cocaine was used to anesthetize the skin. This was a great help in reducing the immediate discomfort of the puncture,
I bet it was.
It is curious how the disease smolders for years in various organs before it manifests in the oddest ways.
Rationalization
Bilateral vertebral artery and internal carotid artery dissecting aneurysms due to syphilis https://www.neurologyindia.com/article.asp?issn=0028-3886;year=2016;volume=64;issue=7;spage=131;epage=133;aulast=
Isolated superficial temporal artery dissection masquerading as giant cell arteritis https://pubmed.ncbi.nlm.nih.gov/19769813/
THE SPINAL FLUID IN PRIMARY AND SECONDARY SYPHILIS https://jamanetwork.com/journals/jama/article-abstract/222952