Syphilitic hepatitis: Case report of an overlooked condition

Syphilitic hepatitis

Syphilis is a sexually transmitted multisystemic disease known as "the great imitator" due to its variable presentations. Despite being preventable and curable, it still constitutes a major health problem. Hepatic manifestation of syphilis is usually mild cholestatic liver injury but in very rare cases can become fulminant. Moreover, syphilitic hepatitis, known for several decades, is considered rare but is probably under-diagnosed. Given the significant morbidity associated with a missed diagnosis, syphilitic hepatitis should be taken into account as an element of differential diagnosis in patients with unexplained elevation of liver enzymes.

Syphilitic Hepatitis: A Rare Cause of Elevated Liver Function Tests

Syphilitic hepatitis is a rare manifestation of syphilis with an incidence of 0.2-38%. We describe a case of a healthy, immunocompetent male patient with elevated liver function tests (LFTs) who was found to have syphilitic hepatitis. A 28-year-old male with no past medical history presented with abdominal pain for two to three weeks. He also reported diminished appetite, intermittent chills, weight loss, and fatigue. His history was positive for high-risk sexual behavior including multiple partners and absence of using protection. His physical examination was remarkable for right-sided abdominal tenderness and a painless chancre on his penile shaft. His workup revealed elevated aspartate aminotransferase (AST: 169 U/L), alanine transaminase (ALT: 271 U/L), and alkaline phosphatase (ALP: 377 U/L). His abdominal CT scan was unremarkable except for the abdominal and pelvic lymphadenopathy. A thorough serology panel revealed negative hepatitis A, B, C, human immunodeficiency virus (HIV) (including HIV RNA), Epstein-Barr virus (EBV), and cytomegalovirus (CMV). His immunological workup was negative as well. His rapid plasma reagin (RPR) was reactive with positive IgG/IgM treponemal antibodies. He was managed as secondary syphilis and received 2.4 million units of benzathine penicillin. Upon follow-up after one week, he reported a complete resolution of his symptoms, and his LFTs were normalized on a repeat checkup. Given the significant morbidity associated with a missed diagnosis, syphilitic hepatitis should be considered an essential part of the workup for evaluating elevated LFTs in an appropriate clinical setting. This case also highlights the importance of obtaining a comprehensive sexual history and performing a thorough genital examination.

Making a Comeback: Syphilitic Hepatitis in a Patient with Late Latent Syphilis-Case Report and Review of the Literature

Treponema pallidum infection has emerged in recent years as an important community threat and burden to the health care system. Here, we report the case of a patient with cholestatic liver disease secondary to late latent syphilis. A 41 year-old male patient was referred to the clinic for assessment of an abnormal liver function panel. Ultrasound of the abdomen demonstrated an intense liver echogenicity, normal bile ducts, and no ascites. Virologic study revealed negative results for antibodies against common viral hepatitis and metabolic and autoimmune disease. The patient was tested for syphilis and a positive result was reported. The patient was diagnosed with late latent syphilis and syphilitic hepatitis and initiated benzathine penicillin at G 7.2 million units total, delivered as three doses of 2.4 million units intramuscular each at one-week intervals. He was assessed monthly and by the end of the sixth month, he had nonreactive VDRL (seroconversion), which confirmed recovery. Syphilitic hepatitis is an overlooked type of hepatitis and should be kept in mind as a differential diagnosis in an abnormal liver panel of uncertain etiology. Health care providers should be advised that higher levels of ALP may be the single landmark in cases of syphilitic hepatitis.

A Case of Syphilitic Hepatitis in an Adolescent

The incidence of syphilis is rising among adolescents necessitating improved provider awareness and screening practices. We present a case of an adolescent with acute hepatitis ultimately diagnosed with secondary syphilitic hepatitis. Clinical presentation, laboratory abnormalities, and histologic features of syphilitic hepatitis are nonspecific, with diagnosis relying on clinical suspicion and targeted testing. This case highlights the importance of screening for syphilis in sexually active adolescents with acute hepatitis. The rising incidence of syphilis among adolescents, and the variety of clinical manifestations including those commonly seen by pediatric gastroenterologists, makes elevated clinical suspicion essential to prompt diagnosis and treatment. With improved provider awareness across general pediatric and subspecialty providers, the transmission of syphilis among adolescent patients can be reduced.

When the Sailor’s Handshake Fails: A Case of Syphilitic Hepatitis in an HIV Patient With Nonspecific Liver Biopsy and Atypical Cutaneous Presentation

Secondary syphilis has variable systemic manifestations, impersonating the presentation of more common pathologies, deceiving clinicians, and creating a difficult-to-diagnose patient. The case discussed combines hepatic syphilis with an uncommon syphilitic dermatologic presentation in a patient with HIV and a history of hepatitis A and B. Due to the challenge of diagnosis, the relative ease of confirming the diagnosis with serological assays, and reversibility of hepatic injury, the inclusion of syphilitic hepatitis on a differential diagnosis of hepatitis is warranted.