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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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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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Hepatic Lesions with Secondary Syphilis in an HIV-Infected Patient. Case Rep Med 2014; 2014:604794. [PMID: 25349616 PMCID: PMC4202275 DOI: 10.1155/2014/604794] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 09/23/2014] [Indexed: 11/18/2022] Open
Abstract
Syphilis among HIV-infected patients continues to be a public health concern, especially in men who have sex with men. The clinical manifestations of syphilis are protean; syphilitic hepatitis is an unusual complication that can occur at any stage of the disease. We report a case of an HIV-infected male who presented with systemic symptoms and liver lesions highly suggestive of lymphoma and was proven to have syphilitic hepatitis by liver biopsy. Our case reinforces the importance of recognizing syphilis as a possible cause of unexplained abnormal liver enzymes and/or hepatic lesions in HIV-infected patients.
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Aggarwal A, Sharma V, Vaiphei K, Duseja A, Chawla YK. An unusual cause of cholestatic hepatitis: syphilis. Dig Dis Sci 2013; 58:3049-51. [PMID: 23925816 DOI: 10.1007/s10620-013-2581-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 01/15/2013] [Indexed: 12/09/2022]
Affiliation(s)
- Abhinav Aggarwal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Crum-Cianflone N, Weekes J, Bavaro M. Syphilitic hepatitis among HIV-infected patients. Int J STD AIDS 2009; 20:278-84. [PMID: 19304979 DOI: 10.1258/ijsa.2008.008324] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Syphilis is an important public health issue and continues to occur at high rates among HIV-infected patients. Although abnormal liver function tests are common among HIV-infected persons, the incidence of syphilitic hepatitis in this population is currently unknown. We present two cases of syphilitic hepatitis and performed a retrospective study to determine the incidence of hepatitis during early syphilis infections among HIV-infected persons. Our study showed that syphilitic hepatitis is common, occurring in 38% (12/32) of HIV-positive patients with early stages of syphilis infection. Most cases occurred during secondary syphilis, with the most common finding being a maculopapular rash. Syphilis should be included in the differential diagnosis of HIV patients presenting with liver test abnormalities, rash and/or sexual risk factors.
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Manifestations extra-cutanéomuqueuses de la syphilis secondaire. Ann Dermatol Venereol 2008; 135:451-8. [DOI: 10.1016/j.annder.2008.03.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 03/28/2008] [Indexed: 11/22/2022]
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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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Cooper C, MacPherson P, Angel JB. Liver toxicity resulting from syphilis and Jarish-Herxheimer reaction in cases of coinfection with HIV and hepatitis C virus. Clin Infect Dis 2006; 40:1211-2. [PMID: 15791529 DOI: 10.1086/428848] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Sabbatani S, Manfredi R, Attard L, Salfi N, Chiodo F. Secondary syphilis presenting with acute severe hepatic involvement in a patient with undiagnosed HIV disease. AIDS Patient Care STDS 2005; 19:545-9. [PMID: 16164381 DOI: 10.1089/apc.2005.19.545] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A case report of acute, massive, prolonged hepatitis related to secondary syphilis in a patient with undiagnosed HIV infection is described together with possible pathogenetic mechanisms. This is a rare occurrence in resource-rich countries in the era of antibiotics. The impaired immune response and the dysregulation of the cytokine network may have played a role in mediating this severe expression of HIV-associated secondary syphilis. An apparently unexplained acute hepatitis should deserve accurate screening for sexually transmitted diseases, including syphilis and HIV infection.
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Affiliation(s)
- Sergio Sabbatani
- Department of Clinical and Experimental Medicine, Division of Infectious Diseases, University of Bologna "Alma Mater Studiorum," S. Orsola-Malpighi Hospital, Bologna, Italy
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The "Great Imitator." Syphilis as Causative Agent of Isolated, Concurrent, Acute Hepatitis and Meningitis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2005. [DOI: 10.1097/01.idc.0000168478.73470.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mullick CJ, Liappis AP, Benator DA, Roberts AD, Parenti DM, Simon GL. Syphilitic hepatitis in HIV-infected patients: a report of 7 cases and review of the literature. Clin Infect Dis 2004; 39:e100-5. [PMID: 15546070 DOI: 10.1086/425501] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Accepted: 07/14/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND A recent resurgence of primary and secondary syphilis has been observed in certain population groups, particularly among persons infected with human immunodeficiency virus (HIV). Liver involvement is an infrequently recognized complication of early syphilis, with no previous reports among HIV-infected patients. METHODS We describe 7 cases of syphilitic hepatitis in HIV-positive individuals and review the literature. RESULTS At our institutions, all patients presented with a rash consistent with secondary syphilis. Each case was characterized by a conspicuous increase in serum alkaline phosphatase level (mean level +/- standard deviation, 905 +/- 523.6 IU/L) and milder elevations in serum transaminase levels. The mean CD4+ absolute T cell count was 317 cells/mm3, and the median rapid plasma reagin (RPR) titer was 1 : 128. There was a significant correlation between higher CD4+ cell counts and the RPR titers (R=0.93; P=.002). Symptomatic resolution and biochemical improvement, particularly a significant decrease in serum alkaline phosphatase levels (P=.02), occurred following antibiotic therapy. CONCLUSIONS Hepatic dysfunction is not uncommon in HIV-infected persons and is attributable to multiple causes. In the appropriate clinical setting, syphilitic hepatitis is an easily diagnosed and reversible etiology of liver dysfunction. The recognition of this entity will prevent unnecessary evaluation of abnormal liver enzyme levels in HIV-positive patients.
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Affiliation(s)
- C J Mullick
- Division of Infectious Diseases, Department of Medicine, George Washington University Medical Center, Washington, DC 20037, USA
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Syphilitic Hepatitis Presenting With Fever and Inguinal Lymphadenopathy Without Rash: A Case Report. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2002. [DOI: 10.1097/00019048-200206000-00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ozaki T, Takemoto K, Hosono H, Miyagawa K, Akimoto S, Nishimura N. Secondary syphilitic hepatitis in a fourteen-year-old male youth. Pediatr Infect Dis J 2002; 21:439-41. [PMID: 12150185 DOI: 10.1097/00006454-200205000-00022] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An unusual case of a secondary syphilitic hepatitis in a 14-year-old male youth is presented. Although he had extremely high aspartate and alanine aminotransferase values, improvement was rapid after antibiotic therapy. Histologic examination of the liver performed during convalescence revealed patchy necrosis and inflammatory cell infiltration.
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Affiliation(s)
- Takao Ozaki
- Department of Pediatrics, Showa Hospital, Kohnan, Aichi, Japan.
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