Snapshot A 40-year-old woman presents to her primary care physician for a wellness exam. She currently does not have any acute concerns and reports to feeling well. She has not seen a physician in 20 years but presents today to be tested for sexually transmitted infections at the request of her new partner. She says she may have had a vaginal sore about 17 years ago. She had many sexual partners and infrequently uses condoms. On physical exam, cardiac auscultation is significant for a tambour-like quality S2 heart sound along with a diastolic decrescendo murmur in the left sternal border. A chest radiograph demonstrates calcifications of the ascending aortic arch. Introduction Clinical definition a cardiac complication of tertiary syphilis, where the vasa vasorum becomes impaired this leads to ischemic injury to the aortic media Pathogenesis believed to be caused by a vasculitis (obliterative endarteritis) of the vasa vasorum, which in turn, weakens the aortic root wall, leading to aortic dilation aortic valve regurgitation Imaging Radiography of the chest findings calcification of the ascending aortic arch (usually) this reflects intimal inflammation