B0618 - Syphilitic Hepatitis With Cholestatic Liver Injury

Monday, October 24, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Sanjeevani Kumar Tomar, MD

University at Buffalo
Buffalo, NY

Sanjeevani Tomar, MD¹, Tiberiu Moga, MD¹, Meghan Cloutier, ², Naren Nallapeta, MD¹, Elizabeth Gregory, MD¹, Emad Alqassim, MD, PhD¹, Yasmin Yusuf, MD¹, Thomas C. Mahl, MD¹
¹University at Buffalo, Buffalo, NY; ²Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY

Introduction: The incidence of syphilis in the United States has increased, predominantly among men who have sex with men. Very few patients with early syphilis meet the criteria for syphilitic hepatitis, but many are HIV⁺ and engage in high-risk sexual behavior.

Case Description/Methods: A 30-year-old man who identified as a MSM presented with yellowing of his eyes and hyperbilirubinemia, preceded by one month with a rash and photosensitivity and redness of his right eye. He denied any penile lesions, history of liver disease or alcohol use.

A physical examination revealed multiple hyperpigmented macular lesions over his torso, arms, palms, and the soles of his feet and scleral icterus. A slit lamp examination indicated anterior uveitis in both eyes and chorioretinitis/placoid retinitis in the right eye. CBC and iron studies showed mild anemia of chronic disease (Hb 11.7 g/dL). BMP was within normal limits. LFTs were as mentioned in Table 1. Blood tests showed positive HBsAb and T. pallidum antibody with RPR 1:128. Serum markers for viral hepatitis and HIV were negative. CSF from a lumbar puncture had an elevated WBC count (9/mm³). No biliary obstruction or masses were noted during on US and MRCP.
Liver biopsy showed bland perivenular cholestasis (zone 3) (Fig. 1A) without necroinflammatory changes, mild to minimal portal inflammation (Fig. 1B), bile duct damage, and ductular reaction.
The patient was treated with penicillin G for neurosyphilis, prednisolone and cyclopentolate for ocular syphilis, and ursodiol for cholestasis. Total bilirubin levels decreased to 1.7 mg/dL after 8 weeks of follow-up, and liver enzymes normalized.

Discussion: This patient met the criteria for syphilitic hepatitis (elevated liver enzymes, serologic evidence of syphilis, exclusion of other etiology, and improvement following appropriate therapy). He also had bilateral anterior uveitis and placoid retinitis of the right eye, suggesting ocular syphilis. Serum chemistries, testing for T. pallidum and other serologies (including positive anti-smooth muscle antibody) supported hepatic involvement, and CSF studies were consistent with neurosyphilis. Liver biopsy showed a bland cholestatic pattern without evidence of other causes of liver disease. The biopsy results are compatible with syphilitic hepatitis, though histologic features can vary and direct staining for spirochetes has limited sensitivity. These findings, together with his rapid improvement with penicillin therapy, confirmed a diagnosis of syphilitic hepatitis.

Figure: Figure 1 (A) Liver specimen (x40 magnification, hematoxylin and eosin stain) showing bland perivenular cholestasis (zone 3 with rare apoptotic hepatocytes. No necroinflammatory activity is present. (B) Liver specimen (x40 magnification, hematoxylin and eosin stain) showing periportal inflammation and bile duct damage with mild bile ductular reaction.

AST	41 IU/L ↑ (ULN < 38 IU/L)
ALT	53 IU/L ↑ (ULN < 42 IU/L)
ALP	210 IU/L ↑↑ (ULN < 129 IU/L)
Total bilirubin	11.6 mg/dL ↑↑ (ULN < 1.3 mg/dL)
Direct bilirubin	8.8 mg/dL ↑↑ (ULN < 0.4 mg/dL)
GGT	53 (ULN < 61 IU/L)
Albumin	3.8 g/dL
INR	1.0

Table: Table 1. Liver function test results (AST, aspartate transaminase; ALT, alanine transaminase; ALP, alkaline phosphatase; GGT, gamma-glutamyl transferase; INR, international normalized ratio; UNL, upper limits of normal).

Disclosures:

Sanjeevani Tomar indicated no relevant financial relationships.

Tiberiu Moga indicated no relevant financial relationships.

Meghan Cloutier indicated no relevant financial relationships.

Naren Nallapeta indicated no relevant financial relationships.

Elizabeth Gregory indicated no relevant financial relationships.

Emad Alqassim indicated no relevant financial relationships.

Yasmin Yusuf indicated no relevant financial relationships.

Thomas Mahl indicated no relevant financial relationships.

Sanjeevani Tomar, MD¹, Tiberiu Moga, MD¹, Meghan Cloutier, ², Naren Nallapeta, MD¹, Elizabeth Gregory, MD¹, Emad Alqassim, MD, PhD¹, Yasmin Yusuf, MD¹, Thomas C. Mahl, MD¹. B0618 - Syphilitic Hepatitis With Cholestatic Liver Injury, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.