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Plesa A, Gheorghe L, Hincu CE, Clim A, Nemteanu R. Making a Comeback: Syphilitic Hepatitis in a Patient with Late Latent Syphilis-Case Report and Review of the Literature. Pathogens 2022; 11:pathogens11101151. [PMID: 36297208 PMCID: PMC9608871 DOI: 10.3390/pathogens11101151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/01/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Alina Plesa
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
| | - Liliana Gheorghe
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Department of Radiology, “Sfantul Spiridon” Hospital, 700111 Iasi, Romania
- Correspondence: (L.G.); (R.N.)
| | - Corina Elena Hincu
- Department of Radiology, “Sfantul Spiridon” Hospital, 700111 Iasi, Romania
| | - Andreea Clim
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Roxana Nemteanu
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
- Correspondence: (L.G.); (R.N.)
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Malvar G, Cardona D, Pezhouh MK, Adeyi OA, Chatterjee D, Deisch JK, Lamps LW, Misdraji J, Stueck AE, Voltaggio L, Gonzalez RS. Hepatic Secondary Syphilis Can Cause a Variety of Histologic Patterns and May Be Negative for Treponeme Immunohistochemistry. Am J Surg Pathol 2022; 46:567-575. [PMID: 34864775 DOI: 10.1097/pas.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The rate of syphilis in the United States has been increasing steadily in the past decade, but it remains an uncommon diagnosis in tissue biopsies. Most of the pathology literature on hepatic syphilis consists of older series or case reports. This study aimed to systematically characterize the histologic spectrum of hepatic syphilis in a contemporary cohort. Clinicopathologic features of 14 hepatic syphilis cases between 2012 and 2018 were analyzed to characterize the broad spectrum of histologic changes. Thirteen patients were men (age range: 19 to 59 y); 6 had known human immunodeficiency virus, 7 were men known to have sex with men, and no patient had known prior syphilis. Hepatic syphilis was the primary clinical suspicion in only 1 patient. Common symptoms included jaundice, rash, and abdominal pain. Thirteen had elevated transaminases, and 12 had elevated alkaline phosphatase. Pathologic changes were grouped into 5 histologic patterns: biliary-pattern injury (n=5), acute hepatitis (n=4), autoimmune hepatitis-like (n=1), fibroinflammatory mass-forming lesion (n=2), and no particular pattern (n=2). Nearly all showed portal and lobular lymphocytes and plasma cells; 12 had prominent histiocytes/Kupffer cells, 9 had ductular reaction, and 7 had duct inflammation. Occasional focal findings included dropout (n=7), phlebitis (n=7), and loose granulomata (n=5). Treponeme immunohistochemistry was positive in 10 and negative in 4, though treatment was given before biopsy in 3 of those 4. Thirteen patients had rapid plasma reagin testing either before or after biopsy, with 1:64 or higher titer. All patients who received treatment recovered. Hepatic syphilis is rare but likely underrecognized. It exhibits a variety of histologic appearances and therefore should be considered in several hepatic differential diagnoses, especially in men who have sex with men. Kupffer cells, granulomata, and phlebitis may suggest the diagnosis regardless of predominant histologic pattern. Negative treponeme immunohistochemical staining does not exclude the diagnosis, including in untreated patients.
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Affiliation(s)
- Grace Malvar
- Beth Israel Deaconess Medical Center
- Department of Pathology, Harvard Medical School
| | - Diana Cardona
- Department of Pathology, Duke University Medical Center, Raleigh, NC
| | - Maryam K Pezhouh
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Oyedele A Adeyi
- Department of Pathology, Toronto General Hospital, Toronto, ON
| | - Deyali Chatterjee
- Department of Pathology & Immunology, Washington University, St. Louis, MO
| | - Jeremy K Deisch
- Department of Pathology and Human Anatomy, Loma Linda University Medical Center, Loma Linda, CA
| | - Laura W Lamps
- Department of Pathology, University of Michigan Hospitals, Ann Arbor, MI
| | - Joseph Misdraji
- Department of Pathology, Harvard Medical School
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Ashley E Stueck
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - Raul S Gonzalez
- Beth Israel Deaconess Medical Center
- Department of Pathology, Harvard Medical School
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Prevalence of Syphilitic Hepatitis Among HIV-Infected Patients in Istanbul, Turkey, a Region with an Increasing Incidence of Syphilis and HIV Infection. HEPATITIS MONTHLY 2020. [DOI: 10.5812/hepatmon.104642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: Syphilis is a global health issue, which continues to occur at high rates worldwide, particularly in HIV-infected men, who have sex with men (MSM). Hepatitis can present as an uncommon manifestation of syphilis, and the diagnosis may be overlooked in favor of more common causes of liver injury in this group. Objectives: This study aimed to determine the prevalence and risk factors of syphilitic hepatitis among HIV-infected individuals diagnosed with acute syphilis. Methods: This cross-sectional study was conducted on HIV-infected individuals who regularly attended a tertiary clinic in Istanbul. The data were collected and analyzed between 2016 and 2019. Cases of syphilitic hepatitis were included according to the following criteria: (I) VDRL-confirmed Treponema pallidum infection after or simultaneously diagnosed with HIV infection; (II) elevated liver enzymes, including ALT, AST, and ALP, that resolved after penicillin treatment; and (III) exclusion of other causes of hepatitis. Sociodemographic characteristics of the participants, clinical and laboratory findings were evaluated using medical records. Results: Among 1,057 HIV-infected patients, 141 (13.3%) were diagnosed to have an early stage of syphilis, 138 of them were male. Nine (6.4 %) out of 141 patients had syphilitic hepatitis, and all of them were self-identified MSM. Moreover, 5 out of these 9 patients were simultaneously diagnosed with syphilis and HIV infection. Up to 10-fold increase in ALT/AST was noted in all of them, and a 3.5-fold increase in bilirubin was observed in two cases. The most prominent laboratory abnormalities in syphilitic hepatitis patients were the detection of a considerable increase in ALP and HIV RNA levels. Conclusions: Syphilitic hepatitis is not encountered rarely in HIV-infected individuals, predominantly MSM populations. Since HIV/syphilis coinfected patients are more infective as a result of higher HIV RNA levels, early diagnosis, and treatment are crucial.
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Marcos P, Eliseu L, Henrique M, Vasconcelos H. Syphilitic hepatitis: Case report of an overlooked condition. Clin Case Rep 2020; 8:123-126. [PMID: 31998501 PMCID: PMC6982489 DOI: 10.1002/ccr3.2588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 11/11/2022] Open
Abstract
Syphilis is an overlooked cause of hepatitis. Syphilitic hepatitis should be a differential diagnosis in all patients with abnormal liver biochemical marker levels. Syphilitic hepatitis has been defined as the combination of increased liver enzymes, positive serology for syphilis, the absence of alternative causes for hepatobiliary injury, and liver enzyme improvement with proper antibiotic therapy.
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Affiliation(s)
- Pedro Marcos
- Gastroenterology DepartmentCentro Hospitalar de LeiriaLeiriaPortugal
| | - Liliana Eliseu
- Gastroenterology DepartmentCentro Hospitalar de LeiriaLeiriaPortugal
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5
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Pizzarossa AC, Rebella M. Hepatitis in patients with syphilis: an overlooked association. BMJ Case Rep 2019; 12:bcr-2018-226918. [PMID: 30696640 PMCID: PMC6350734 DOI: 10.1136/bcr-2018-226918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 01/01/2023] Open
Abstract
We present the case of a patient who sought treatment for fever and a maculopapular rash involving the trunk, limbs, palms and soles. The patient also presented with hepatomegaly and elevated levels of liver enzymes (with a higher increase of alkaline phosphatase). With the proposal of early syphilitic hepatitis, during the stage of secondary syphilis, a venereal disease research laboratory and Treponema pallidum haemagglutination tests were requested, which confirmed the diagnosis. All altered parameters improved with antibiotic treatment for secondary syphilis. Syphilitic hepatitis is an often overlooked presentation of syphilis and should be considered as a differential diagnosis in patients with elevated levels of liver enzymes and risk factors for syphilis.
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Affiliation(s)
| | - Martín Rebella
- Clínica Médica C, Hospital de Clínicas, Montevideo, Uruguay
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Huang J, Lin S, Wan B, Zhu Y. A Systematic Literature Review of Syphilitic Hepatitis in Adults. J Clin Transl Hepatol 2018; 6:306-309. [PMID: 30271743 PMCID: PMC6160304 DOI: 10.14218/jcth.2018.00003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/12/2018] [Accepted: 03/03/2018] [Indexed: 01/19/2023] Open
Abstract
Syphilitic hepatitis in adults is not frequently found in the population and is easily misdiagnosed. The incidence of viral hepatitis is increasing year by year, concomitantly increasing the importance of obtaining a systematic understanding of the clinical features and treatment strategies for this disease. There is, however, a lack of published definitive data regarding the clinical characteristics, diagnosis and standard treatment options for this disease. Searches were made using the MEDLINE database of PubMed and OVID for syphilitic hepatitis publications from 1951 to 2017 in an attempt to analyze and summarize the clinical characteristics.
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Affiliation(s)
- Jiaofeng Huang
- Liver Research Center of the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Su Lin
- Liver Research Center of the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Bo Wan
- Institute of Neurology, University College London, London, UK
| | - Yueyong Zhu
- Liver Research Center of the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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7
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Honrubia-López R, Rueda-García JL, Burgos-García A, Fernández-Martos R, Mora-Sanz P. Acute hepatitis as a manifestation of secondary syphilis. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:505-506. [PMID: 29054317 DOI: 10.1016/j.gastrohep.2017.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/18/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Raúl Honrubia-López
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España.
| | | | | | | | - Pedro Mora-Sanz
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
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8
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Ferreira-González L, Caínzos-Romero T, Fernández-Fernández FJ, Sesma P. Hepatitis colestásica como forma de presentación de sífilis secundaria. Enferm Infecc Microbiol Clin 2013; 31:487-8. [DOI: 10.1016/j.eimc.2012.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/19/2012] [Accepted: 12/21/2012] [Indexed: 10/27/2022]
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9
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Lee M, Wang C, Dorer R, Ferguson L. A great masquerader: acute syphilitic hepatitis. Dig Dis Sci 2013; 58:923-5. [PMID: 22833383 DOI: 10.1007/s10620-012-2322-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 07/07/2012] [Indexed: 12/09/2022]
Affiliation(s)
- Maximilian Lee
- Liver Center, Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Ave., Mailstop C3-GAS, Seattle, WA 98101, USA.
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Manavi K, Dhasmana D, Cramb R. Prevalence of hepatitis in early syphilis among an HIV cohort. Int J STD AIDS 2012; 23:e4-6. [PMID: 22930309 DOI: 10.1258/ijsa.2009.009386] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To investigate the prevalence of syphilitic hepatitis among a group of HIV-infected patients we performed a cross-sectional observational study of consecutive HIV-infected patients with early syphilis attending University Hospital Birmingham between 1 January 2005 and 31 August 2008. The AIDS Clinical Trials Group grading for abnormal liver enzymes was used to identify hepatitis. A total of 62 HIV-infected patients were diagnosed with early syphilis during the study period. Twelve (19.3%) of them demonstrated abnormal liver enzymes consistent with syphilitic hepatitis involving raised levels of alanine aminotransferase, aspartate transaminase, alkaline phosphatase or gamma-glutamyl transferase (GGT). Grade 3 hepatotoxicity was observed among five patients. None of the patients with syphilitic hepatitis had grade IV hepatitis or abnormal bilirubin levels. Liver biopsy was not carried out in any of the patients, and following completion of treatment of syphilis all abnormal liver enzymes returned to normal levels after a median of 16 weeks. Exclusion of syphilis must be considered when investigating hepatic disease in HIV-infected patients.
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Affiliation(s)
- K Manavi
- Department of GUM, Selly Oak Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
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11
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Gibson DG, Oller KL, Lezama J. The great "infiltrator": an uncommon cause of hepatitis. Am J Med 2012; 125:1068-70. [PMID: 22935560 DOI: 10.1016/j.amjmed.2012.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 06/12/2012] [Accepted: 06/12/2012] [Indexed: 11/24/2022]
Affiliation(s)
- Dennis G Gibson
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA.
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13
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Ferreira-González L, Rubín De Celis EP, Sesma P. Neurosífilis tras tratamiento de hepatitis sifilítica en un paciente inmunocompetente. Enferm Infecc Microbiol Clin 2012; 30:274-5. [DOI: 10.1016/j.eimc.2012.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/16/2012] [Accepted: 01/18/2012] [Indexed: 10/28/2022]
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Case of secondary syphilis presenting with unusual complications: syphilitic proctitis, gastritis, and hepatitis. J Clin Microbiol 2011; 49:4394-6. [PMID: 21998411 DOI: 10.1128/jcm.01240-11] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report the first known case of syphilis with simultaneous manifestations of proctitis, gastritis, and hepatitis. The diagnosis of syphilitic proctitis and gastritis was established by the demonstration of spirochetes with anti-Treponema pallidum antibody staining in biopsy specimens. Unusual manifestations of secondary syphilis completely resolved after 4 weeks of antibiotic therapy.
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15
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Koenig M, Bageacu S, Delorme MP, Perrot JL, Cambou M, Cuilleron M, Lambert M. [Asthenia, fever, jaundice in a 59-year-old man]. Rev Med Interne 2010; 31:318-20. [PMID: 20223567 DOI: 10.1016/j.revmed.2009.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- M Koenig
- Service de médecine interne, hôpital Nord, CHU de Saint-Etienne, 42055 Saint-Etienne cedex 2, France.
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Miura H, Nakano M, Ryu T, Kitamura S, Suzaki A. A case of syphilis presenting with initial syphilitic hepatitis and serological recurrence with cerebrospinal abnormality. Intern Med 2010; 49:1377-81. [PMID: 20647651 DOI: 10.2169/internalmedicine.49.3414] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We present the case of an immunocompetent 50-year-old Japanese man with a cerebrospinal fluid (CSF) abnormality relevant to syphilis; his original presentation was liver dysfunction, the etiology of which was uncertain until positive serology for syphilis was identified. Liver dysfunction was promptly resolved after oral penicillin therapy; however, serological recurrence developed. CSF abnormality associated with syphilis was confirmed by subsequent lumbar puncture. Syphilis should be included in the differential diagnosis of patients with liver dysfunction of unknown etiology, and possible neurosyphilis should be considered when the treatment becomes refractory, even when there is no evidence of neurological manifestations.
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Affiliation(s)
- Hideaki Miura
- Department of Internal Medicine, Social Insurance Central General Hospital, Tokyo, Japan.
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Hepatitis luética. Una entidad emergente. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:610-3. [DOI: 10.1016/j.gastrohep.2009.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 05/03/2009] [Accepted: 05/29/2009] [Indexed: 11/21/2022]
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Noto P, Del Nonno F, Licci S, Chinello P, Petrosillo N. Early syphilitic hepatitis in an immunocompetent patient: really so uncommon? Int J STD AIDS 2008; 19:65-6. [DOI: 10.1258/ijsa.2007.007037] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The incidence of syphilis has increased substantially over the past years, particularly in men who have sex with men. The clinical manifestations of syphilis are variable and liver involvement is uncommon, but may occur at any stage of the disease. We report a case of early syphilitic hepatitis (ESH) in an immunocompetent patient referring multiple bisexual exposures, who presented at admission with jaundice, tiredness, an ulcerated genital lesion and an increase of liver aminotransferases. During his hospital stay, he developed a skin rash, and serology for syphilis was found positive. Our case report strengthens the need to take into consideration the diagnosis of ESH in all patients with unexplained liver enzyme increase and epidemiological data of unsafe sexual exposures. Indeed, an early recognition of the clinical manifestations of syphilis can lead to a prompt treatment, and allows the prevention of the transmission of this disease to other individuals.
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Affiliation(s)
- P Noto
- Clinical Department, 2nd Infectious Diseases Division, Via Portuense, 292 – 00149 Rome, Italy
| | - F Del Nonno
- Department of Pathology, National Institute for Infectious Diseases ‘L Spallanzani’, Via Portuense, 292 – 00149 Rome, Italy
| | - S Licci
- Department of Pathology, National Institute for Infectious Diseases ‘L Spallanzani’, Via Portuense, 292 – 00149 Rome, Italy
| | - P Chinello
- Clinical Department, 2nd Infectious Diseases Division, Via Portuense, 292 – 00149 Rome, Italy
| | - N Petrosillo
- Clinical Department, 2nd Infectious Diseases Division, Via Portuense, 292 – 00149 Rome, Italy
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Affiliation(s)
- Clinton L Greenstone
- Veterans Affairs Ann Arbor Medical Center, Ambulatory Care Division (11A), 2215 Fuller Rd., Ann Arbor, MI 48105, USA.
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