Uniformed Services University of the Health Sciences, United States
Lindsay D. Kingston, 1, Jared S. Magee, DO, MPH2, Adam Tritsch, MD3 1Uniformed Services University of the Health Sciences, Bethesda, MD; 2Walter Reed National Military Medical Center, Rockville, MD; 3Walter Reed National Military Medical Center, Bethesda, MD
Introduction: Abnormal liver associated enzymes (LAE) are a common consult question for gastroenterologists and are correlated with mortality and morbidity (1). Determining the etiology for liver injury relies on a thorough history and diagnostic testing for specific diseases. Syphilitic hepatitis (SH) is a rare cause of acute liver injury that can mimic autoimmune (AI) diseases of the liver including primary biliary cholangitis (PBC) and AI hepatitis. We present a case of syphilitic hepatitis mimicking AI diseases of the liver.
Case Description/Methods: A 34-year old man with a history of high risk sexual activities presented to the emergency room with 3 weeks of constant epigastric pain with associated fatigue, dark urine and inability to tolerate regular diet. Labs during initial evaluation were notable for a hemoglobin of 12.9 g/dl, an alkaline phosphatase of 616 U/L, total bilirubin of 3.7 mg/dl, ALT of 290 U/L and AST of 209 U/L. Further workup of elevated LAEs, would reveal a positive antinuclear antibody, smooth muscle antibody, mitochondrial antibody, and elevated serum IgG to 2117 mg/dl. An MRCP revealed conglomerative porta hepatis nodes concerning for possible lymphoma. Endoscopic ultrasound (EUS) guided fine needle aspiration of the lymph nodes showed no evidence for any lymphoproliferative disorder. EUS guided liver biopsy during evaluation of mass revealed an epithelioid granuloma. Given his sexual history, a treponema pallidum antibody was ordered and found to be positive. The decision was made to treat without any additional testing using a single dose of 1.2 million units of intramuscular bicillin. The week following therapy he had resolution of his symptoms and over the following month had resolution of all lab and imaging abnormalities.
Discussion: The overall incidence of SH is unknown. Liver injury can occur in up to 40% of cases of early syphilis, most commonly with a disproportionately elevated alkaline phosphatase (2). Proposed diagnostic criteria of SH includes: abnormal LAE levels; serological evidence for syphilis; exclusion of other causes of liver diseases; LAE levels returning to normal after antimicrobial therapy (3). Our patient met all criteria for SH and had resolution of all autoantibodies and radiologic findings following treatment. There is an unclear relation between autoantibodies and syphilis, but gastroenterologists should be aware of this unusual cause of liver injury in patients with high risk sexual behaviors and labs suggestive of AI liver disease.
Lindsay Kingston indicated no relevant financial relationships.
Jared Magee indicated no relevant financial relationships.
Adam Tritsch indicated no relevant financial relationships.
Lindsay D. Kingston, 1, Jared S. Magee, DO, MPH2, Adam Tritsch, MD3. P1893 - The Great Imitator: Syphilitic Hepatitis Presenting as a Mimic to Autoimmune Liver Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.