Kirk Kerkorian School of Medicine at UNLV Las Vegas, NV
Blaine Massey, DO, Kyaw Min Tun, DO, Zahra Dossaji, DO, Dimal Patel, MD Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV
Introduction: Syphilis, a STI caused by Treponema pallidum, is often referred to as the “Great Imitator.” The incidence of syphilis has been rising throughout the U.S. since 2001. Recent CDC data reveal 133,945 cases of all stages in 2020, a 52% increase from 2016. The exact incidence of SH in early syphilis is thought to be roughly 3%, but this is likely underestimated. We present the case of a HIV-negative male with secondary syphilis and syphilitic hepatitis (SH).
Case Description/Methods: A 33-year-old healthy male presented with malaise and painless rash for 3 weeks. Other symptoms included fevers, chills, night sweats, weight loss, decreased appetite, sore throat, and odynophagia. History was negative for abdominal pain, substance use, primary chancre, sexual activity with men. Exam revealed jaundice, pharyngitis without mucosal lesions, nontender cervical lymphadenopathy, and a papulosquamous rash involving the trunk, penile shaft, and soles of feet (Fig 1). Initial labs showed hyperbilirubinemia, alkaline phosphatase in the 1000s, and moderately elevated transaminases (Table 1). HIV, acute hepatitis panel, anti-mitochondrial and smooth muscle antibodies were negative. Notably, syphilis antibody immunoassay was positive, with reflex RPR titer of 1:128. CT and ultrasound showed hepatomegaly (20.2cm) without focal liver lesions (Fig 1), and mild gallbladder wall thickening (4mm). Patient was treated with one dose of benzathine penicillin G 2.4M units. Symptoms resolved within 24 hours. A clinical diagnosis of SH was made, and liver biopsy was not performed. Abnormal liver enzymes seen while inpatient normalized over the course of 2 months.
Discussion: While syphilis rates continue to rise, we can expect to see SH more frequently. Disproportionate elevations of ALP and GGT are frequently seen, likely due to pericholangiolar inflammation. A disproportionate elevation in ALP can be an important clue present in most patients with SH, with relatively lesser elevations in transaminases and moderate hyperbilirubinemia. It is important to note that SH can mimic other causes of acute liver injury such as autoimmune hepatitis and primary biliary cholangitis. Proposed diagnostic criteria for SH include: abnormal liver enzymes, clinical presentation of secondary syphilis with positive syphilis serologies, absence of other causes of liver injury, and improvement in liver enzymes after antibiotics. SH should be high on the differential for patients presenting with acute liver injury and maculopapular rash.
Figure: A. Papulosquamous rash of the penile shaft B. Resolving hyperpigmented papulosquamous rash involving the soles of bilateral feet C. CT abdomen with contrast (coronal view) demonstrating hepatomegaly, liver (arrow) measuring 20.2cm
Blaine Massey indicated no relevant financial relationships.
Kyaw Min Tun indicated no relevant financial relationships.
Zahra Dossaji indicated no relevant financial relationships.
Dimal Patel indicated no relevant financial relationships.
Blaine Massey, DO, Kyaw Min Tun, DO, Zahra Dossaji, DO, Dimal Patel, MD. D0592 - The Great Imitator Strikes Again: A Case of Syphilitic Hepatitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
