Barnard, C.N.

Beck, W.

Schrire, V.

English

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2 Julje 1966 S.A. TYDSKRIF VIR GENEESKUNDE 553SYPHILITIC CORONARY OSTIAL OCCLUSION*V. SCHRIRE, M.sc., PH.D., M.D., ER.C.P. (LaND. AND EDlN.), F.A.C.C., C. N. BAR ARD, M.D., M.MED., M.S.,PH.D., AND W. BECK, M.Sc., M.MED., M.R.C.P.; From The Cardiac Clinic, and The CSIR Cardiovascular-PulmonaryResearch Group, Department of Medicine, and the DepartmenT of Surgery, Groote Schwlr HospiTal alld UniversiTYof Cape TownnSyphilitic ostial occlusion or stenosis is a rare disease.Scharfman et al.,' in 1950, reviewed several large necropsyseries and analysed 935 cases of syphilitic aortitis in33,176 necropsies. The coronary ostia were involved in 24.Heggtveit,' more recently, reviewed 100 cases of syphiliticaortitis in a necropsy series of over 13,000 patients fromBrooklyn, New York. Coronary ostial stenosis occurred in26, i.e. in more than a quarter of the patients. The rightostium was involved in 5, the left in 6 and both in IScases. The involvement was marked in 15 of these cases.and syphilitic coronary arteritis was present in only 1 case:Cardiac infarction was present in 24 patients. In 17,coronary atherosclerosis was responsible and in 3 bothsyphilis and atherosclerosis were implicated. Syphiliticostial occlusion was the main or sole factor in 4 of these.Sudden death due to ostial stenosis occurred in 5. Heggt-veit rightly drew the conclusion that cases of syphiliticcoronary ostial stenosis are particularly prone to be re-garded simply as examples of coronary atherosclerosis.With the development of cardiac bypass, surgical cureis now possible. Successful treatment by coronary ostialendarterectomy has previously been reported by Frenchworkers'" in 5 patients and by ourselves' in 2 patients.Connolly et al.· published a report on a patient in whomostial occlusion was thought to be due to atheroma.diaphragrnatic infarction developing after the procedure.It is important to think of syphilis as a cause of coro-nary disease. There may be no clinical clues and the ECGis unhelpful. Of a series of over 150 patients withsyphilitic heart disease seen by one of us (V.S.) in theCardiac Clinic, Groote Schuur Hospital, no more than 5have been clearly recognized as suffering from coronaryostial occlusion. The diagnosis can now be readily madeby coronary arteriography. This procedure was of parti-cular value in a patient with atypical chest pain and pro-gressive heart failure in whom surgery was curative.CASE REPORTC.F., a 54-year-old Coloured male, was first seen in the Car-diac Clinic at the age of 48 complaining of left-sided chestpain. burning in nature and first noticed while lifting a heavyweight at work. The pain was not generally related to effort.Clinical examination was negative, the blood pressure was150/90 mm.Hg and the X-ray was normal. Repeat ECGsshowed transient flattening of the T waves in VI and V6. Anunequivocally positive effort test was obtained (Fig. I). A diag-nosis of atypical chest pain with latent coronary artery diseasewas made.The patient was lost to follow-up for 5 years, and was thenreferred back after mass radiography had shown cardiome-galy. He then stated that since his first examination the left-sided chest pain had continued, lasted about t-hour at a time,could be provoked by effort and was relieved by rest andT T. This symptom had remained stationary, but for severalyears he had become increasingly dyspnoeic on effort so thathe had been forced to alter his occupation. For I monthbefore admission, he had characteristic attacks of paroxysmal*Paper presented at the 45th South African Medical Congress(MAS.A.), Port Elizabeth, July 1965.2cardiac dyspnoea associated with slight left chest pain. Thiswas followed by swelling of the feet. There had been no pro-longed attacks to suggest cardiac infarction. On examinationhe had definite cardiomegaly, with a loud apical triple rhythm.Fig. I. The resting ECG is normal. Immediately after effort patholo-gical left axis deviation develops, which soon returns to normal.Unequivocal ST segment depression due to cardiac ischaemia develops.The X-ray confirmed the cardiomegaly, and showed well-marked pulmonary congestion. The ECG had altered, show-ing pathological left axis deviation, with a widened QRS andabnormal T waves suggesting anterolateral parietal block (Fig.2).He was admitted for treatment and study. After digitaliza-tion and diuretics, there was a good response. A soft, inter-mittent, early diastolic murmur became audible in the fourthleft space. The serology was positive and the sedimentationrate was 8 mm. per hour. A diagnosis of luetic coronary ostialdisease with cardiac ischaemia and slight aortic incompetencewas made.Cardiac catheterization confirmed the presence of mildaortic incompetence with a raised end-diastolic left ventricularpressure-145/5-25. The right coronary artery filled well. butthere was narrowing of the lumen at or close to the ostium.554 S.A. MEDICAL JOURNAL 2 July 1966left coronary artery was demonstrated and dilatation of theascending aorta was present.A week later, surgery was performed with cardiac bypass.Dilatation with several saccular aneurysms of the aorta wasfound, the aorta being adherent to the surrounding structures.Severe intimal changes with calcification were present. Theleft coronary ostium was completely occluded and the rightostium partly occluded by syphilitic endarteritis. Minimalaortic incompetence was present. The saccular aneurysms wereresected. Great difficulty was encountered in finding the orificeof the left coronary artery. After extensive endarterectomy thisarea was located. The small orifice was completely cleaned upwith good back-flow from the right coronary artery. Thisartery was not endarterectomized. The postoperative coursewas complicated by severe mental depression which graduallysettled.Within 2 months of surgery, the patient's condition im-proved strikingly, all chest pain disappeared and he was freeof dyspnoea. The early diastolic murmur was barely audibleand the gallop rhythm had disappeared. There was a clearreduction in heart size (Fig. 4). No cardiac therapy was re-quired. .Reinvestigation 3 months after surgery showed patentcoronary arteries. Both vessels could now be selectively cathe-terized. The ostium of the left coronary was half the size ofthe right, but filled normally (Fig. 5). Collateral filling of theleft coronary was no longer present. An aortic angiogram (Fig.6) showed both coronary arteries filling from the aorta andtrivial aortic incompetence was present. The left ventricularpressure curve, however, had not yet returned to normal (LVP160/15 - 27) and the electrocardiogram was unchanged.Fig. 2. The two ECGs done at an interval of 5 years are contrasted.The initial tracing is within normal limits; the later tracing showspathological left axis deviation with a widened QRS and abnonnal Twaves suggesting anterolateral parietal block.-j--r++-····...··;·+·~-+--', QVF ;·~-~f"";The left coronary appeared diminullve and filled late andretrogradely from the posterior-mtraventricular branch of theright coronary artery (Fig. 3). Ostial occlusion of the mainFig. 3. Selective coronary angiography shows a dominant right coronary artery which is markedly enlarged. The left coronary is diminutive and fillslate and retrogradely from the posterior intraventricular branch of the right coronary.Fig. 4. The marked reduction in heart size and disappearance of pulmonary venous congestion is shown within the short space of 3 months aftersurgery.Fig. 5. Selective coronary angiography postoperatively now· shows patency of both coronary ostia. Although the left coronary artery is small, it fillsdirectly from the aorta and the retrograde anastomotic channels have disappeared. Note the reduction in the size of the left ventricle.Fig. 6. An aortic angiogram before and after surgery is contrasted. Before operation only the right coronary artery fills and is enormously dilated.After operation both eoronary vessels fill directly from the aorta. Trivial aortic incompetence is present.2 Julie 1966 S.A. TYDSKRIF VIR GE 'EESKU DE 555DISCUSSIONCardiovascular syphilis has become a rarity in most coun-tries, since the introduction of penicillin treatment has allbut eliminated the tertiary manifestations of the disease.In South Africa, however, syphilis still remains an im-portant cause of heart disease. Thus it accounts for Q·6 %of all cases of cardiovascular disease at Groote SchuurHospital.' In non-Whites I - 2% of heart disease is dueto syphilis-IQ times higher than in Whites. Moreover,recent reports in the literature suggest that syphilis is againon the increase"Syphilis should always be considered when angina pec-toris is encountered in the younger age-group, especially ifother evidence of aortitis is present. Disproportionateangina in the presence of mild aortic incompetence isstrongly suggestive of this condition. Positive serologicaltests are supportive evidence, but may be an incidentalfinding in a patient with coronary atherosclerosis.The only certain way of establishing the diagnosis is bycoronary angiography; the obstruction is localized to thecoronary ostium, the rest of the coronary vascular treebeing normal. The appearance is quite unlike coronaryatherosclerosis where the obstructions are generally mul-tiple and situated distal to the ostia.A full course of penicillin may sometimes be of valuebut has been very disappointing in our experience. Surgeryis required to relieve the narrowed coronary ostia. It wasof considerable benefit to our patient, even though themain manifestations were those of progressive heart failuredue to myocardial disease. Presumably restoration ofcoronary blood flow relieved myocardial ischaemia andthe heart failure was reversible.SUMMARYA case of atypical left chest pain, probably anginal in nature.wiIh progressive heart failure culminating in acute paroxysmalnocturnal dyspnoea and severe disability, has been described.Auscultation initially revealed a gallop rhyIhm only, but laterwith control of the heart failure a soft early diastolic murmurbecame audible. Syphilitic coronary ostial disease was con-firmed by coronary arteriography, normality restored by sur-gery, and a striking benefit resulted for the patient.Syphilitic ostial disease must always be considered if anginapectoris occurs in a young man; if aortic incompetence ispresent; if the ascending aorta is dilated or calcified; or if dis-proportionate angina pectoris is present in the presence ofaortic incompetence.We wish to thank Dr. J. G. Burger, Medical Superintendentof Groote Schuur Hospital, for permission to publish. Ourspecial thanks are due to the Council for Scientific and In-dustrial Research and the City Council of Cape Town fortheir continued financial support.REFERE CE~I. Scharfman. W. B., Wallach. J. B. and August, A. (1950): Amer. HeartJ .. 40. 603.2. Heggtveit, H. A. (1964): Circulation. 29. 346.3. Blondeau, P. and Dubost, C. L. (1962): Ann. Chir. !horae. cardiov.,1. 802.4. Michau, P., Froment, R .. Pont, M., Saubier, E. and Aimard, G.(1963): Lyon chir., 59. 575.5. Beck, W., Barnard. C. N. and Schrire. V. (1966): Brit. Heart J., 27, 911.6. Connolly, J. E., Eldridge. F. L., Calvin, J. W. and Stemmer, E. A.(1964): New Engl. J. Med.. 271, 213.7. Schrire, V. (1964): S. Afr. Med. 1.. 38, 598.8. US Department of Health, Education and Welfare (1962): VD FactSheer. Publication no. 341. Washington. DC: Dept. of Health, Educa-tion and Welfare, Public Health Service.ALOPECIA AFTER TICK BITEJAMES MARSHALL, M.D., Department of Dermatology, 5lellenbosch UniversityFew parasites are as versatile as ticks in causing or trans-mitting diseases in man and domestic animals. The dis-orders of man in which ticks are involved are the follow-ing.'"Dermatoses. Acute local reactions include pain, itch,urticarial swelling, subcutaneous haemorrhage, necrosisand ulceration. Chronic reactions include ulceration; per-sistent papules, nodules or tumours whose histologicalappearances may suggest squamous carcinoma or somebenign or malignant disease of the reticulo-endothelialsystem,' eczema and lichenification and allergic reactionsakin to papular urticaria: Tick bites are often sites forsecondary bacterial infections and occasionally for myiasis.Envenomization. Inoculation of toxic salivary fluids mayresult in severe systemic disturbances with generalizedurticaria and vomiting (ixodism).Tick paralysis. A toxin elaborated by some ticks causesan acute ascending flaccid paralysis which, in children, maybe mistaken for infantile paralysis. Affected adults usuallyhave paralysis of a limb.Otoacariasis. Some ticks favour the auditory canal as afeeding site.Infections transmitted. Diseases conveyed to man byticks include rickettsioses (e.g. Rocky Mountain spottedfever; South African tick-bite fever), viroses (e.g. Coloradotick fever; louping ill), spirochaetoses (tick-borne relapsingfever), and bacterial infections (tularemia and, perhaps,erypsipeloid). Erythema chronicum migrans and acroder-matitis chronica atrophicans are almost certainly due tosome micro-organism transmitted by ticks,' and the list oftick-borne diseases is constantly being lengthened.I have recently seen two patients with an unusualcutaneous reaction, alopecia of the scalp, following tickbite.Case ReporlsThe patients were children, a While boy aged 7 years anda Cape Coloured boy of 2 years. The sequence of events wasidentical in both. The mother accidentally discovered a tickfirmly attached to the scalp and picked it off. Over the nextweek the hair fell out in a circle, 3 cm. in diameter around thebite, leaving the area quitt bare. There was no systemicdisturbance.The children were first seen about 10 days after removal ofthe tick when hair loss had ceased (Fig. I). In the centre ofthe bare area was a little scab which was removed to uncovera tiny clean depression. The bare scalp was normal in allrespects except that the surface was slightly scaly. A fewlong hairs remained, but there were no stumps or exclamation-mark hairs such as are often found in alopecia areata. Hairsin the marginal area were normal and there was no increase

Syphilitic coronary ostial occlusion

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Syphilitic coronary ostial occlusion

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