# Case Report: Syphilitic proximal coronary stenosis with discordant serology: diagnostic validation by optical coherence tomography

## TL;DR

A 70-year-old man with chest tightness and conflicting syphilis tests was diagnosed with syphilitic heart disease using advanced imaging.

## Contribution

Demonstrates the diagnostic utility of optical coherence tomography in confirming syphilitic vasculitis despite discordant serology.

## Key findings

- Optical coherence tomography revealed syphilitic vasculitis features like vasa vasorum obliteration and elastic lamina fragmentation.
- The patient had no systemic atherosclerosis, as shown by zero coronary calcium score and normal carotid thickness.
- Successful treatment followed OCT-guided intervention and targeted antibiotics.

## Abstract

Cardiovascular syphilis, a late manifestation of Treponema pallidum infection, remains a diagnostic challenge, particularly when serological tests are discordant. We report a case of a 70-year-old male with recurrent chest tightness and discordant syphilis serology (non-reactive RPR, reactive TPPA). Coronary angiography revealed a critical stenosis at the distal left main coronary artery, specifically involving the ostio-proximal segment of the left anterior descending (LAD) artery. Critically, the absence of systemic atherosclerosis was evidenced by a coronary artery calcium score of zero and normal carotid intima-media thickness. Optical coherence tomography (OCT) provided definitive diagnostic clarity by revealing microstructural features pathognomonic for syphilitic vasculitis: vasa vasorum obliteration, elastic lamina fragmentation, and adventitial fibrosis with microcalcifications. These findings were distinct from atherosclerotic plaque. The patient successfully underwent OCT-guided percutaneous coronary intervention followed by targeted antibiotic therapy. This case highlights the indispensable role of OCT in establishing the etiology of non-atherosclerotic proximal coronary stenosis, underscoring that cardiovascular syphilis must be considered even with non-reactive non-treponemal tests in late-stage disease.