Gummatous mitral valve endocarditis from tertiary syphilis

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.