An autopsy on a 58-year-old man who died of heart failure reveals a dilated aneurysm of the ascending aorta. The intimal surface shows wrinkled, longitudinal creases resembling tree bark. Microscopy shows destruction of the vasa vasorum with plasma cell infiltrates around the adventitial vessels. What is the underlying cause?

• A Hypertensive cystic medial degeneration
• B Giant cell arteritis
• C Tertiary syphilis ✓
• D Ehlers-Danlos syndrome type IV

Explanation

Syphilitic aortitis is a manifestation of tertiary syphilis. Treponemes involve the vasa vasorum of the ascending aorta, producing obliterative endarteritis with perivascular plasma cell cuffs. Ischemic injury to the media leads to loss of elastic fibers and smooth muscle, dilatation, and the characteristic tree-bark intima. Ascending aortic involvement is typical because this region is rich in vasa vasorum. Giant cell arteritis is granulomatous and occurs in elderly patients, while cystic medial degeneration lacks the plasma cell vasculitis.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.