Introduction: Hepatitis is acute inflammation of the liver, and it is most often caused by viral infections (Hepatitis A, B, C), as well as by alcohol, toxins, and other causes. This can be acute or chronic in nature, and will often present with symptoms including fatigue, nausea and vomiting, and jaundice. Elevated liver enzymes will aid in diagnosis. However, when some of the most common causes have been ruled out, additional evaluation is performed into less common causes. We present a case of acute hepatitis secondary to syphilis.
Case Description/Methods: The patient is a 38-year-old male who presented with increasing fatigue and abnormal liver enzymes. He also noted lower extremity swelling as well as the presence of a new rash all over his body. He denied any nausea, vomiting, fevers, abdominal pain, constipation or diarrhea. He denied any recent medication changes, and denies smoking, alcohol use, and illicit drug use. Family history was unremarkable. There was no history of blood transfusion. The patient reports being sexually active with multiple female partners in the past. A CMP was significant for an ALP of 451, AST 155, and ALT 240. Bilirubin was normal. A CBC showed a hemoglobin of 11.7 with an MCV of 76.8. His most recent CBC and LFTs from four months prior were normal. Of note, Hep B/C, HIV, HSV, GC, and Chlamydia all recently tested negative. Serologic studies for ANA, ASMA, ceruloplasmin, alpha-1 antitrypsin, and iron panel all were normal.
The patient states that he tested positive for syphilis during plasma donation. A red, macular rash was present on the palms of his hands, soles, and lower legs. Treatment with IM Penicillin G was initiated. Following treatment, his LFTs were trended, which revealed ALP of 438, AST 54, and ALT 114. The patient was advised to follow-up with his PCP to assess for symptom resolution.
Discussion: Syphilis is an infection that can present with a variety of different symptoms. Though syphilis and hepatitis has been rarely associated in the past, it is a rare cause, and delayed diagnosis can result in significant patient morbidity. Many patients will note a characteristic painless, genital lesion. However, this can go unnoticed or underreported by the patient as it self-resolves. While it is incredibly sensitive to penicillin, prompt diagnosis can be challenging, and late stages of syphilis can result in irreversible complications.
