syphilitic cardiovascular disease
Introduction
Introduction to syphilitic cardiovascular disease Syphilitic cardiovascular disease (syphilitic cardiovascutardisease) is a cardiovascular disease caused by the cardiovascular system in late stage (phase 3), including syphilitic aortitis, syphilitic aortic regurgitation, syphilitic aorta Tumor, coronary stenosis and myocardial gelatinous swelling. Most syphilis is acquired, and congenital syphilis is rare. Although cardiovascular syphilis is rare, it still exists. The disease progresses slowly, from 10 to 25 years after the initial infection with syphilis (5 years in the fast, 40 years in the slow), the patients are mostly 35 to 50 years old, and the male to female ratio is 4:1 to 5:1. basic knowledge The proportion of illness: 0.004% Susceptible people: no specific population Mode of infection: blood transmission Complications: aortic aneurysm aortic insufficiency heart failure
Cause
Causes of syphilitic cardiovascular disease
(1) Causes of the disease
Treponema pallidum invades the ascending aorta (35%):
When the Treponema pallidum invades the human body from the damaged mucosa, it can invade the lymph nodes and various parts of the body (such as liver, kidney, lung, heart, bone and joint, brain, etc.) in about half an hour, some of which are Treponema pallidum. The lungs invade the aorta's nourishing blood vessels, and the lesions are mostly in the ascending aorta, which rarely invade the myocardium. The reason may be that there is more lymphatic tissue in the ascending aorta, and there is very little lymphatic drainage in the myocardium. After that, symptoms and signs of the lesion appear after more than 10 to 25 years, but a few can also develop symptoms within 1 to 2 years.
Treponema pallidum invades the human body and causes an immune response (25%):
After invading the human body for 8 to 9 weeks, the spirochete continuously proliferates in the human body and causes secondary lesions in the body. If this time is not effectively treated, Treponema pallidum can produce an immune response in the human body, and the spirochete is gradually reduced, which produces The immune status may include cellular and humoral immunity, cellular immune response: localized delayed allergic reaction can be confirmed after 1 to 2 days; it can also be confirmed from the third-stage syphilis-like lesion, humoral immunity: humoral immunity including responsiveness and spirochete The increase of the antibody and the responsiveness indicates that the lesion is active; the spirochete antibody indicates the state of the immune response after infection, usually one month after infection with syphilis, which can be maintained for life, can inhibit the reproduction and activity of the spirochete, due to the immune response, Some patients may have immune complex lesions, such as nephritis.
(two) pathogenesis
After the invasion of the body, Treponema pallidum produces immunological effects of cellular immunity and humoral immunity. During different periods of syphilis infection, the host's immunity also changes and exerts different immunological effects. One to three weeks after the onset of sputum in the first stage, The body produces a variety of antibodies against different antigenic components of Treponema pallidum, mainly by cardiolipin antibodies and anti- Treponema pallidum antibodies. It is currently believed that anti-cardiolipin antibodies do not have any immunoprotective effects, and anti- Treponema pallidum antibody protection is also limited, mainly due to syphilis In the course of the disease, especially in the secondary syphilis, the antibody may have a high titer, but the Treponema pallidum can still multiply and spread. The cellular immune effect is currently considered to play an extremely important immunoprotective role in the course of syphilis. Early syphilis patients treated with regular smear treatment showed significant cellular immunosuppression. For example, the proportion of CD4 + and CD4 + / CD8 + T cells in T cell subsets was lower than that in normal control group, while CD8 + was significantly higher than normal control group; The ability of peripheral blood mononuclear cells (PBMC) to produce interleukin22 (IL22) is getting lower and lower as the disease progresses, Sa Lazar J. C et al [6] found that the ratio of CD4 + / CD8 + T cells predominates from primary syphilis CD4 + T cells to secondary leap to CD8 + T cells, and Fitzgerald is based on cytokine secretion patterns. Primary syphilis is dominated by the fact that Th1 (helper T cell 1) predominates and secondary syphilis is converted to Th2 (helper T cell 2).
Pathological changes (15%):
The pathological changes of the disease are inflammatory changes in the aorta, especially the ascending aorta, and fibrous scar formation, causing syphilitic aortitis, aortic regurgitation, aortic aneurysm, coronary stenosis, and myocardial lesions. Rare.
The middle layer of the ascending aorta, which is rich in lymphatic vessels, is most susceptible to direct invasion by Treponema pallidum. The outer membrane nourishes the blood vessels and infiltrates lymphocytes and plasma cells, which leads to occlusion of nourishing blood vessels, resulting in arterial intimal fibrosis, destruction of middle muscles and elastic fibrous tissue. And necrosis, followed by scar formation, necrosis and scarring of the middle aorta caused by bark-like wrinkles in the endothelium of the lesion, the wrinkles parallel to the long axis of the aorta, covered by flashing pearl plaque, the main lesion Involved in the ascending aorta (above the aortic sinus), followed by the aortic arch, thoracic descending aorta, and the innominate artery, the common carotid artery and abdominal aorta are rarely involved, and the renal artery is not tired.
When the ascending aortic lesion extends to the aortic root, the aortic annulus is enlarged, and the aortic valve leaf junction is separated to cause aortic regurgitation; when the lesion involves the aortic valve leaf attachment, the aortic valve closure is further aggravated. Not complete.
Due to the middle aortic lesions, the aortic wall is gradually thinned and accompanied by calcium deposition, resulting in weakening or disappearance of the aortic wall elasticity, aortic expansion or aortic aneurysm, aortic aneurysm mostly occurs in the ascending aorta or aortic arch It is sacred, with thrombus inside, and can be detached to cause peripheral obstruction or compression of peripheral organs and tissues, resulting in corresponding compression symptoms, but does not cause aortic dissection.
When the lesion involves the aortic sinus, it can cause fibrous lesions and scar formation in the aortic wall, causing coronary stenosis and obstruction.
Myocardium is rarely involved, and occasionally a gum-like swelling can occur, or myocardial hypertrophy, fibrosis or myocardial ischemia due to aortic regurgitation or coronary stenosis.
Prevention
Syphilitic cardiovascular disease prevention
1. It is strictly forbidden to promote the use of condoms, establish new ethics, new fashions, prohibit illegal sexual contacts as necessary measures to prevent the spread of syphilis, prevent drugs and actively prevent the spread of AIDS.
2. Syphilis serum reaction should be routinely performed when suffering from other sexually transmitted diseases.
3. Sexual partners of syphilis patients should be observed and examined regularly.
4. Pre-marital physical examination should routinely include syphilis serum reaction test. 5. Apply penicillin to patients with early syphilis, follow up the serum test, and repeat the treatment if necessary.
Complication
Syphilitic cardiovascular disease complications Complications aortic aneurysm aortic insufficiency heart failure
7 to 10 weeks after syphilis infection, or 6-8 weeks after hard chancre, treponema pallidum can enter the systemic bloodstream from the local lymphatics, almost invading the various organs of the body. For the cardiovascular system, it mainly attacks the ascending aorta, followed by the aortic arch. , descending aorta, common carotid artery, abdominal aorta, which destroys the middle layer of muscle tissue and elastic fibers of the aorta and produces inflammation, occlusive endarteritis and perivascular inflammation, accompanied by monocytes, lymphocytes and plasma Infiltration of the cells, so that the aortic roots expand, the annulus enlarges and even different degrees of aortic regurgitation, eventually leading to heart failure; it can also cause the formation of aortic aneurysm, aortic insufficiency, aortic aneurysm rupture, etc. Complications, occasionally myocardial gelatinous swelling, severely localized to the left, right ventricular outflow tract, resulting in obstruction of blood and heart enlargement.
Symptom
Symptoms of syphilitic cardiovascular disease Common symptoms Severe pain, patent ductus arteriosus, chest pain, dizziness, dyspnea, systolic murmur, nod signs, hoarseness, bronchoconstriction, sudden death
The syphilitic aortic aneurysm has different clinical manifestations due to its different sites. The following clinical types are common:
Simple syphilitic aortitis
Syphilitic aortitis is the most common form of syphilitic cardiovascular disease. More than 80% of untreated syphilis patients develop syphilitic aortitis, most of which are asymptomatic, so they are also called asymptomatic Arteritis, some patients may feel post-sternal discomfort or dull pain.
The clues suggesting the presence of syphilitic aortitis are the second heart sound enhancement in the aortic valve area of the drum sound and the rough systolic jet murmur, but it is difficult to diagnose syphilitic aortitis by these signs alone. X-ray examination The diagnosis value is large, and the ascending aorta can be widened. The vascular widening extends along the thoracic cavity and can extend to the transverse iliac. Since the abdominal aorta does not widen, the descending aorta is funnel-shaped, and the other has diagnostic significance. It was found that the linear calcification of the ascending aorta was found in about 20% of patients. This change usually occurred several years after the occurrence of syphilitic aortitis. Aortic sclerosis can also occur calcification, but it occurs in the descending aorta of the thoracic artery. Blocky.
2. Syphilitic aortic regurgitation
Aortic regurgitation is the most common complication of syphilitic aortitis. In 20% to 30% of patients, approximately 20% of patients with syphilitic aortic regurgitation have coronary stenosis, but saccular artery Tumors are rare.
Syphilitic aortic regurgitation is seen in patients with advanced syphilis. The initial diagnosis is 40 to 55 years old, usually male, and the degree of aortic regurgitation can range from very mild to severe.
(1) Mild aortic regurgitation: The main findings of auscultation are as follows:
1 The second heart sound of the aortic valve area is enhanced with a drum sound.
2 Follow the second heart sound of the aortic valve in the second intercostal space on the right side of the sternum to detect dilated early diastolic murmur.
3 may smell the early jetting sound.
When the loud aortic valve systolic murmur coexists with mild aortic valve diastolic murmur, or when mitral stenosis or dysfunction murmur is heard, syphilitic aortic regurgitation may be excluded, mild aorta The Austin-Flint murmur did not occur with the flap closed.
Doppler echocardiography revealed aortic root widening, aortic annulus enlargement, and aortic regurgitation.
The hemodynamic disorder of syphilitic mild aortic regurgitation is very mild and requires no special treatment. The importance of diagnosis lies in the application of antibiotics to these patients, but even after a sufficient amount of antibiotic treatment, there are still years after May develop severe aortic regurgitation.
(2) Moderate to severe aortic regurgitation:
1 Symptoms: The main symptoms of severe aortic regurgitation are pulmonary congestion and left heart failure, labor or paroxysmal nocturnal dyspnea, and the course progresses rapidly in 1 to 3 years. Finally, pulmonary edema and right heart occur. Depletion, due to massive aortic valve regurgitation, reducing blood flow to the head and coronary arteries, can produce dizziness, syncope and angina pectoris, due to the often associated coronary stenosis, the degree of angina is not commensurate with the degree of aortic regurgitation .
2 Signs: The apex beat point shifts to the left and the left, the apex beats or the lifted pulsation, and the percussion heart dullness enlarges to the left. Due to the widening of the ascending aorta and the aortic arch, the second intercostal lobe of the right sternum is widened. Cardiac auscultation found more, described as follows:
A. The second heart sound can still be drum sound, but the intensity is weakened, and the second heart sound can disappear in severe cases.
B. The second intercostal space of the right sternum is next to the aortic valve. The second heart sound can be heard loud and high-profile, accounting for the diastolic murmur of the whole diastolic period. The noise is transmitted downward along the right edge of the sternum more than the left sternal border. The intensity of conduction, the murmur can be transmitted to the apex and sacral line. Unlike rheumatic aortic insufficiency, the latter often has mitral valve disease and right ventricular enlargement, which makes the heart rotate clockwise, so the murmur is in the sternum. The third intercostal space on the left edge is the clearest, the murmur is transmitted down the left sternal border, and the right sternal murmur is lighter, but the Marfan syndrome, osteogenesis imperfecta, etc. due to significant aortic root expansion caused by aortic regurgitation, The diastolic murmur is also clearly seen in the second intercostal space on the right sternal border and is transmitted downward along the right sternal border. The syphilitic aortic valve insufficiency is sometimes musical or "gull sound", which can be widely transmitted to the entire chest wall. It can be heard without even using a stethoscope. This noise is caused by the edge of the valve, especially the regular vibration of the non-crown valve edge. The most common disease of this nature is the syphilitic aortic valve insufficiency. System is that the expansion of the aortic annulus extending flap edge and loss of support, impulse everted blood flow to the left ventricle is reversed vibration generated rules.
C. The upper part of the right sternal border and the upper sternal fossa can smell loud and rough systolic jet murmur: enhanced in the early stage of contraction, short duration, conduction to the neck, sometimes accompanied by systolic tremor, tremor can be in the neck or sternum The upper fossa is stunned, but rarely in the aortic valve area. The jet systolic murmur of rheumatic aortic stenosis lasts longer, and is enhanced in the middle or late stage of contraction. It is different from the above murmur, syphilitic aorta The systolic murmur that occurs when the flap is incomplete does not indicate a true aortic valve or left ventricular outflow stenosis, but rather a high flow of blood flow through the stiff, irregular aortic valve into the dilated and widened aortic root to create eddy currents. Caused.
D.Austin-Flint murmur: Patients with moderate-to-severe aortic regurgitation often hear this murmur at the apex of the apex. It is light in nature and is a low-profile rumbling-like diastolic murmur. It is more limited, sometimes it needs to be left after the activity. The position can be heard with a bell-shaped stethoscope. The mechanism may be that the blood flow from the aorta to the left ventricle hits the mitral valve main valve, resulting in functional mitral stenosis. The murmur is not enhanced before the systole, without The first heart sound hyperthyroidism or mitral flap sound, so it can be differentiated from rheumatic mitral stenosis.
E. Aortic valve area contraction early jet sound: Some patients can hear it, it is caused by a large amount of blood in the early stage of contraction through the dilated aorta, causing sudden expansion of vibration.
Moderate-to-severe aortic regurgitation can also produce the following peripheral vascular signs:
a. Diastolic blood pressure reduction and pulse pressure widening: The diastolic blood pressure of patients with moderate aortic regurgitation is below 40 ~ 50mmHg, and the diastolic blood pressure of patients with severe aortic regurgitation can be 0.
b. Corrigan's collapsing pulses: Due to the rapid filling of the arteries around the systolic phase, part of the blood in the diastolic phase flows back to the left ventricle, and the intravascular pressure drops rapidly, and the pulse is powerful.
c.Quincke's capillary pulses: slightly pressurize the nails, or gently press the lip mucosa of the patient with a slide. Both red and white alternating small blood vessels are seen.
d. de Musset's head bobbing: The head makes a nod to the heart beat.
e. Traube's pistol shots and Duroziez's sign: Place the stethoscope on the brachial artery or femoral artery, and hear a loud gunshot sound when the artery beats; a little pressure, you can also hear arterial systole Noise; re-pressurization, systolic, diastolic murmur, called Du's double murmur.
(3) ECG examination: there may be changes in the left axis of the electric axis and left ventricular hypertrophy, and some patients may find atrial fibrillation.
(4) X-ray examination: X-ray shows that the heart is enlarged to the left and the lower rear, and severe aortic valve insufficiency can make the heart appear in the shape of a shoe, and the ascending aorta is obviously widened (syphilitic aortitis).
(5) Doppler echocardiography: Aortic root widening, increased mobility, aortic ring enlargement, left ventricular enlargement and aortic regurgitation can be measured, and aortic valve backflow can be measured.
(6) retrograde aortic angiography: the diastolic contrast agent flows back into the left ventricle, and the degree of aortic insufficiency can be estimated according to the degree of contrast agent reflux. For example, the contrast agent reflux to the left ventricle is more dense than the aorta. That is to say, it is severely closed.
3. Coronary stenosis
Coronary stenosis is the second major complication of syphilitic aortitis, with an incidence of 20% to 26%. The lesion is localized in the coronary ostia, and in rare cases can extend into the coronary artery, but usually does not exceed 1cm.
Angina pectoris is the most common manifestation of coronary stenosis. Most of them have a typical episode. Coronary stenosis can cause sudden death. Due to the slow process of stenosis, the collateral circulation is fully developed, so myocardial infarction rarely occurs, even if the disease is mild. Coronary stenosis often coincides with aortic regurgitation or aneurysm, but sometimes it is the only syphilitic atherosclerotic complication. Coronary stenosis can cause left ventricular dysfunction without angina or aortic valve closure. Not complete.
In syphilitic cardiovascular disease, angina can occur in severe aortic regurgitation, or in coronary stenosis with or without aortic regurgitation, or in patients with coronary atherosclerotic stenosis, selective coronary If the angiography is not carefully observed, the coronary stenosis can be missed. The pressure is obviously attenuated after the catheter enters the coronary artery, or the aortic sinus is returned without backflow after injecting the contrast agent. All of them suggest the presence of coronary stenosis. In patients with narrow mouth, non-selective coronary angiography, injecting contrast into the aortic sinus is valuable for diagnosis.
4. syphilitic aortic aneurysm
Aortic aneurysm is the least common complication of syphilitic aortitis, with an incidence of 5% to 10%, 1/3 of the incidence of syphilitic aortic regurgitation, and about 50% of syphilitic aortic aneurysms. Ascending aorta, 30% to 40% in the aortic arch, 15% in the descending thoracic aorta, aortic aneurysm usually in the shape of a capsule, or a spindle shape, the aortic aneurysm has a thick fibrous wall, often with scaly attachment Thrombosis, because the tumor wall is fibrous tissue, it is not easy to have aortic dissection, aortic aneurysm is mostly single, the incidence of multiple aortic aneurysms is only 4% to 7%.
(1) Clinical manifestations: The clinical manifestations of syphilitic aortic aneurysm are mainly caused by the surrounding structure of the compression and the rupture of the aneurysm, and are determined by the location of the aortic aneurysm. Because the aneurysm compresses the nerve or erodes the bone, the patient often has pain. The pain is usually persistent, and it can develop into severe pain in the later stage, accompanied by pulsation, the patient is deeply tortured, the aortic aneurysm is different, and the pain is different. It can occur on both sides of the sternum, upper, middle, lower back or upper. abdomen.
1 syphilitic ascending aortic aneurysm: ascending aortic aneurysm can be large and relatively few symptoms, called "aneurysm of signs", ascending aortic aneurysm can compress the superior vena cava, right bronchus and Right pulmonary artery, compression of the superior vena cava produces superior vena cava syndrome, manifested as facial and upper extremity edema, neck, upper limb and chest wall venous engorgement, exophthalmos and conjunctival edema, compression of right bronchus produces atelectasis, repeated lungs Infection, irritating dry cough and difficulty in breathing, right pulmonary artery compression can be localized and systolic jet murmur, ascending aortic aneurysm can compress the sternum, local elevation and obvious pulsation at the 1st and 2nd intercostals of the right front chest. It can also touch the pulsatile mass in the sternal fossa, such as the rupture of the aortic aneurysm, the right bronchus, the right pleural cavity or pericardium, causing hemoptysis, pericardial and pleural hemorrhage, and aneurysm can also be worn. The skin on the chest wall is worn out before.
2 syphilitic aortic arch aneurysm: aortic arch aneurysm, even if it is not large, it is easy to oppress the surrounding structure in the early stage of symptoms, called "symptom aortic aneurysm" (aneurgsm of symptoms):
A. Compression of the esophagus causes difficulty in swallowing.
B. Compression of the left bronchus causes bronchoconstriction or atelectasis, the patient has asthma, and the symptoms in the right lateral position or sitting position are reduced, and vice versa.
C. Compression of the left recurrent laryngeal nerve causes hoarseness, vocal cord paralysis and metallic cough.
D. Compression of the phrenic nerve causes hiccups and diaphragmatic spasm.
E. Compression of the left stellate ganglion caused Horner syndrome, manifested as left eyelid drooping and mild eyeball invagination, left pupil diminished, no sweat on the left face and elevated skin temperature.
F. Compression of the large vein produces the superior vena cava syndrome.
J. Pressing the opening of the innominate artery causes the pulse and blood pressure of the upper limbs to be different.
Aortic arch aneurysm can have a pulsatile mass in the anterior chest wall or neck. When the aortic arch aneurysm ruptures, the perforating site is the esophagus, trachea and mediastinum, respectively, causing hematemesis, hemoptysis or mediastinal shadows rapidly widening, or through the front chest wall Worn out.
3 syphilitic descending aortic aneurysm: descending aortic aneurysm can be very large and asymptomatic or physical signs, often found in routine chest X-ray, or for chest X-ray examination for the diagnosis of other diseases, aortic aneurysm compression of the left bronchus Coughing and difficulty breathing, compression of the lungs can cause secondary lung infection, compression of the common pulmonary artery in the pulmonary valve area to hear systolic jet murmur, a small number of patients in the posterior chest wall such as the left scapular angle below the pulsatile mass, such as The aneurysm ruptures, and the site of perforation is the esophagus, left bronchus, left pleural cavity or left lung parenchyma.
4 syphilitic abdominal aortic aneurysm: the incidence of syphilitic abdominal aortic aneurysm in syphilitic aortic aneurysm is less than 5%, the main clinical manifestations of abdominal pulsatile mass, syphilitic abdominal aortic aneurysm generally occurs above the renal artery This point is different from abdominal aortic aneurysm caused by atherosclerosis, which usually occurs at or below the renal artery, and breaks through the retroperitoneal space when the abdominal aortic aneurysm ruptures.
Thoracic descending aortic aneurysm and abdominal aortic aneurysm can even compress the spinal nerve roots, causing severe pain, vertebral atrophy, spinal cord compression.
5 aortic sinus aneurysm: aortic sinus aneurysm, caused by syphilis about 6%, but syphilitic aortic sinus tumor may be the most common cause of acquired aortic sinus tumor, such as aneurysm occurs in the left and right Aortic sinus, can press the left and right coronary artery mouth to cause angina, such as aneurysm in the posterior sinus of the aorta (no coronary sinus), often without any symptoms and signs, X-ray examination is also normal.
The most frequently broken part of the aortic sinus aneurysm is the right ventricle, right atrium or pulmonary artery. It has a unique clinical manifestation. The patient can have palpitations, chest tightness or chest pain, cough, wheezing, and tremor in the left chest. Then, the appearance of right heart failure gradually appeared, but some patients may not have the feeling of sudden onset of symptoms. The signs are continuous, loud, machine-like murmurs in the left and third sternal borders of the sternum, similar to congenital patent ductus arteriosus. Continuous murmur, 2nd heart sounds in the pulmonary valve area, diastolic blood pressure decreased, pulse pressure widened, water pulse and gunshot sound appeared, sinus tumor was broken into the left atrium, and the sign was continuous murmur on the left back. In the presence of left heart failure, retrograde aortic angiography can confirm the rupture of the sinus tumor.
The systolic vascular murmur is often heard in the syphilitic aortic aneurysm. When the syphilitic aortic regurgitation is combined, the signs of aortic regurgitation are present at the same time.
(2) imaging examination: X-ray examination can find the aortic bulge in the location of the aortic aneurysm, most of which are located in the ascending aorta and aortic arch, showing an expansive pulsation, and the linear calcification is a characteristic manifestation. Erosion of the sternum, ribs and vertebrae, esophageal swallowing may be found to be displaced by the esophagus. Aortic aneurysm needs to be differentiated from mediastinal shadows caused by other causes, such as lymphoma, thymoma, and dermoid cyst. Identification is sometimes not easy because Sometimes there is no obvious pulsation in the aortic aneurysm, and the mediastinal mass near the aorta may also appear to be pulsating. The aortic aneurysm is sometimes large and the chest X-ray is normal. Aortic angiography can accurately show the presence or absence of an aortic aneurysm. Location, extent, and condition of branch artery involvement.
Echocardiography can detect aortic aneurysms at the root of the aorta. Transesophageal echocardiography can be used to detect aneurysms of the ascending aorta. Other noninvasive imaging techniques such as radionuclide angiography, computed tomography, and magnetic resonance imaging. Imaging, digital subtraction angiography, etc. can clearly show the location and size of aortic aneurysm. Computed tomography and magnetic resonance imaging can also clearly show the relationship between aneurysms and adjacent tissues. These examination techniques are used to identify whether aortic aneurysm is syphilitic. , yet has not accumulated enough experience.
Examine
Examination of syphilitic cardiovascular disease
Serological tests for syphilis are important for diagnosis and are helpful for diagnosis when they are positive.
(1) Serological examination The scope of syphilis serology is low specificity, sensitivity to high specificity, and sensitivity mainly includes the following methods.
1. Wassermans test, the Kahns test used to be used in serological tests for syphilis, has now been replaced by more sensitive and more specific methods.
2. Non-helical serum test (non-specific heart-month antibody) has VDRL test (veneral disease reseorch laboratories), RPR (rapid plasma pheromone ring card test and APT (automatic responsive factor) test, often used In the syphilis screening, the positive rate of syphilis in the VDRL test is 70%, the positive rate of syphilis in the second stage is 99%, and the positive rate in the late syphilis (including cardiovascular and neurosyphilis) is 70%, if the initial stage of HIV infection and stage II syphilis The response of the test can be delayed or the positive rate is reduced.
3. Treponema pallidum test includes Treponema pallidum immobilization test (TPI test), fluorescent trepomal antibody absorption test (FTA-ABS test) and Trebospira microhemagglutination MHA -TP) were positive. The positive rate of syphilis in the FTA-ABS test was 70% in the initial stage, 99% in the stage II syphilis, and 98% in the late stage syphilis. It can be used as a confirmed test for cardiovascular and neurosyphilis. In the positive test, the sensitivity of the MHA-TP test in the initial syphilis is worse than that of the VDRL test and the FTA-ABS test, but the sensitivity and specificity of the stage II and late syphilis are similar to those of the FTA-ABS, even if the patient is treated, FTA-ABS remains positive for life.
4. Tremella IgG antibody assay (Western blot test) has the characteristics of FTA-ABS test, 99% sensitivity and 88% specificity, easy to operate, especially for cases suspected of repeated infection, congenital syphilis and syphilis mixed with HIV Infected.
(2) Imaging examination
1. Chest X-ray examination of simple syphilitic aortitis can be seen in the proximal aortic dilatation, about 20% of patients with ascending aorta see clue-like calcification, while aortic atherosclerosis often has a block in the thoracic descending aorta Hardening, ascending aortic calcification often occurs several years after the occurrence of syphilitic aortitis. In syphilitic aortitis, the aortic node and the descending thoracic aorta can be calcified, but with the proximal head, the ascending aorta is most calcified at the brachial artery. Widely, the calcification of the aortic node and the thoracic descending aorta is most prominent in atherosclerosis. The syphilitic aortitis begins at the root of the aorta and can extend distally, up to the diaphragm. The aorta is widened. When there is aortic regurgitation, the heart is enlarged to the left and the rear. The heart and the aorta pulsate sharply under the screen. The aorta is found in the corresponding aorta. Bulging, expansive pulsation, ascending aorta or aortic arch tumor can erode bone destruction visible in adjacent bones, and there may be calcification in the tumor wall.
2. CT and MRI examination CT (computed tomography, computerized tomography) for the screening of suspected cases of chest X-ray, can accurately measure the size of aneurysm, its accuracy is no less than ultrasound contrast and angiography, is A particularly attractive new technique, MRI (magnetic resonance imaging), which provides high-resolution static images with high diagnostic accuracy for thoracic aortic lesions, can show cystic aneurysms, true size of aneurysms, and Characteristics, the relationship with the surrounding inflammatory response, the relationship between the extent of aneurysm involvement and the aortic arch, is highly sensitive and specific for the detection of heart valve regurgitation.
3. Ultrasound examination Echocardiography can show different segmental widening, calcification, aneurysm (including aortic sinus aneurysm) and aortic regurgitation, detection of aortic regurgitation by ultrasound Doppler, detection of left ventricular size, room Wall thickness, left ventricular end-systolic and end-diastolic pressure and volume, ejection fraction, etc., showed abnormal mitral valve activity including anterior diastolic flutter, showing aneurysm size, location and rupture site.
4. Cardiovascular retrograde aortic angiography shows the location and size of aortic aneurysm, degree of aortic regurgitation, left ventricular size, cardiac function, etc. Selective coronary angiography for syphilitic cardiovascular disease patients with angina and doubt In the case of coronary stenosis, the coronary artery stenosis is limited to the opening, while the distant coronary artery has no stenosis, which is different from coronary atherosclerosis. According to statistics, 20% to 80% of syphilitic aortitis The patient has a narrow coronary stenosis.
Diagnosis
Diagnosis and diagnosis of syphilitic cardiovascular disease
Differential diagnosis
Patients with syphilis cardiovascular disease have a history of smelting, with typical syphilis or advanced syphilis clinical manifestations, positive syphilis serological response, diagnosis is not very difficult, but should be related to rheumatic valvular disease, atherosclerotic heart disease Heart murmurs and some other diseases are identified.
(1) Identification of heart valve murmur
1. Aortic valve area: Aortic valve murmur caused by diastolic murmur syphilitic aortic root dilatation, due to root expansion, the second rib gap murmur in the right sternal border sounded the loudest, while rheumatic aortic valve regurgitation The flow, due to the mitral valve disease often accompanied by enlargement of the right ventricle, the heart is translocated, so the diastolic murmur is most loud in the third intercostal space on the left sternal border.
2. Aortic valve area: systolic murmur syphilitic aortic regurgitation in this area can be heard in the area of the slap-like contraction of early jet sounds and systolic murmur, while rheumatic aortic stenosis has a higher murmur tone Tip, during contraction, late enhancement, aortic atherosclerotic calcification, proximal aortic dilation, although the valve itself has no stenosis (relative stenosis), systolic jet murmur can also be heard, but it is enhanced early in contraction, and The noise time lasts for a short time.
3. Mitral valve area: diastolic murmur syphilitic aortic valve severe reflux to the left ventricle blood flow impact on the mitral valve main flap, resulting in functional mitral stenosis caused by diastolic rumbling-like murmur (Austin-Flint Noise (noise), no pre-systolic enhancement, without apical first heart sound enhancement and mitral open slap sound, and rheumatic mitral stenosis caused by diastolic rumbling murmur with pre-systolic enhancement, apex The first heart sound enhancement and the mitral valve open beat sound.
(B) Identification of serotoxicity false positive reaction
1. VDRL false positive reaction in the acute infection period of the disease (within 6 months), to be differentiated from atypical pneumonia, malaria and other bacterial or viral infections, during the chronic infection period of the disease (over 6 months), Identification of autoimmune diseases (such as systemic lupus erythematosus), drug use, leprosy, and false positive reactions in a few elderly people. These false positives have a titer of 1:8 or lower, and these patients should be followed for long-term follow-up.
2. FTA-ABS false positive systemic lupus erythematosus cases have a false positive reaction, which may be a beaded fluorescence caused by anti-DNA antibodies, different from the true syphilis positive results, should be closely followed.
(three) identification of angina
Angina pectoris is the most common clinical manifestation of syphilitic coronary stenosis. Due to the slow progression of the disease and the support of collateral circulation, myocardial infarction rarely occurs. Of course, there is also the presence of coronary atherosclerosis. Heart disease is early, often at night, and the attack lasts longer.
