Gummatous mitral valve endocarditis from tertiary syphilis

  1. Nisha George
  2. Daniel Pan
  3. Shirley Sze
  4. Caroline Williams
  5. Zein El-Dean
  6. Victor Zlocha
  7. Elizabeth Webb
  8. Manish Pareek

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Abstract

A 50-year old Romanian gentleman presented with fever, myalgia and 30kg weight loss. He was treated for syphilis previously, after acquiring it from his ex-wife 16 years ago. On examination, there was a pansystolic murmur in the axilla, and the patient had an ataxic gait. Blood tests showed raised inflammatory markers. However, standard investigations for infective endocarditis, including multiple blood cultures, serological titres for fastidious organisms and antibody tests were negative.   CT of the chest, abdomen and pelvis demonstrated hepatosplenomegaly with multiple splenic infarcts. MRI of the head with contrast showed multiple punctate enhancement in the bilateral hemispheres with leptomeningeal enhancement. Transthoracic echocardiogram demonstrated large vegetation leading to severe mitral regurgitation. Serum treponemal antibodies were positive; TPPA was positive at 1:1280 and RPR: 1:4 Treponemal IgM was negative; lumbar puncture syphilis serology was negative. The patient was treated with an extensive period of intravenous antibiotics, in addition to a prosthetic metallic valve replacement, where unusual ragged calcified valvular tissue was observed.    Tertiary syphilis is a difficult diagnosis to confirm, since it can often be indolent and occur in areas of the body where they may go unnoticed. In our case, a diagnosis of syphilitic endocarditis was made from a combination of the history, an initial increase in size of the lesion following antibiotic therapy and observation of likely gumma on the mitral valve during surgery. In such cases, surgery in addition to optimal antimicrobial therapy is necessary for effective treatment.

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  2. Access Microbiology

    Comments to Author

    Dear Dr. Pareek Thank you for providing point by point responses to the comments and applying relevant edits to the manuscript. I found your response sufficient and the manuscript suitable for publication. Best regards Rahsan Erdem, M.D.

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  3. Version published to 10.1099/acmi.0.000817.v2 on Access Microbiology
  5. Access Microbiology

    Comments to Author

    Please see my suggested edits below 1. In the abstract section, case description includes the clause that he acquired the infection from his ex-wife, this is not a relevant or needed information, please consider removing, and simply specifying "sexually acquiring 16 years ago etc.. 2. Describe the physical exam finding in more detail, including fever and myalgia grade 3. Pat8ent is previously to during his incarceration, but the case does not provide any details on the tx length, potential success or immediate failure. Consider adding more details to provide insight on the immediate tx failure or incomplete tx risk in the past including the length of the tx regimen. 4. Line 95 and 99 provide conflicting timelines to the antibiotic tx, review and revise as needed. 5. Starting on line 95, provide additional physical exam findings or reported symptom listing to the case, as applicable. Please check the manuscript for punctuation throughout.

    Please rate the quality of the presentation and structure of the manuscript

    Very good

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  6. Access Microbiology

    Comments to Author

    Please ONLY put comments for the Author(s) in here Interesting case of probable tertiary syphilis; I think the authors should clearly write in the discussion that the case is a probable tertiary syphilis; the diagnose is not sure since they did not find the spirochetes in the mitral valve tissue through laboratory investigations, as well as immunohistochemical staining for T. pallidum, as previously described: Drago F, Ciccarese G, Tomasini CF, Calamaro P, Boggio M, Rebora A, Parodi A. First report of tertiary syphilis presenting as lipoatrophic panniculitis in an immunocompetent patient. Int J STD AIDS. 2017 Mar;28(4):408-410. doi: 10.1177/0956462416665973. Epub 2016 Sep 27. PMID: 27558164. Moreover, tha authors should consider the fact that this probable tertiary syphilis developed despite the antibiotic therapy for syphilis performed decades ago; this case highlights the fact that the conventional treatment with penicilline for syphilis may be inadequate to prevent late complications, as previously suggested: Drago F, Ciccarese G, Broccolo F, Sartoris G, Stura P, Esposito S, Rebora A, Parodi A. A new enhanced antibiotic treatment for early and late syphilis. J Glob Antimicrob Resist. 2016 Jun;5:64-6. doi: 10.1016/j.jgar.2015.12.006. Epub 2016 Jan 21. PMID: 27436469.

    Please rate the quality of the presentation and structure of the manuscript

    Satisfactory

    To what extent are the conclusions supported by the data?

    Partially support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  7. Version published to 10.1099/acmi.0.000817.v1 on Access Microbiology