Syphilitic hepatitis in HIV-infected patients: a report of 7 cases and review of the literature

Hepatic Lesions with Secondary Syphilis in an HIV-Infected Patient

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.

A case of secondary syphilis demonstrating nephrotic syndrome and a solitary intrahepatic mass in a human immunodeficiency virus-1-infected patient

A 37-year-old, human immunodeficiency virus-1-infected Japanese man was referred because of nephrotic syndrome following emergence of generalized skin rash. Serological tests for syphilis turned out to be positive within ten months of the referral. Abdominal echography incidentally revealed a solitary intrahepatic mass without a detectable blood flow in segment 7. The patient's signs and symptoms, as well as the intrahepatic mass, resolved promptly after administration of amoxicillin. We consider that, in the present case, secondary syphilis caused the nephrotic syndrome and the intrahepatic mass, both of which have rarely been reported to date.

Syphilitic hepatitis: an uncommon manifestation of a common disease

Hepatitis being first manifestation of secondary syphilis is rare. Here in we report a case of 39 years old male who was being treated for hepatitis and presented to us subsequently with itchy maculopapular rash. Venereal disease research laboratory (VDRL) titre was 1:16. Treponema pallidum hemagglutination assay (TPHA) was positive. He was treated with intramuscular Benzathine Penicillin. His hepatitis improved rapidly.

Rash and hepatitis within days of starting a new antiretroviral regimen: nevirapine hypersensitivity, secondary syphilis or both?

We report a case in which an HIV-positive man developed general malaise, skin rash and biochemical hepatitis within days of starting a nevirapine-based antiretroviral treatment regimen. At the same time, his syphilis serology proved positive. We discuss the diagnostic dilemma: was this a nevirapine hypersensitivity reaction, secondary syphilis or both?

Syphilis as a diagnosis of liver abnormalities in HIV

In order to investigate syphilitic liver involvement in HIV-infected patients, a single-centre retrospective study of a cohort of HIV-infected patients with syphilis was performed at the Infectious Diseases Clinic of Perugia, Italy, between December 2002 and March 2010. Fifty HIV-infected patients were identified with syphilis plus baseline and follow-up liver tests. The following syphilis diagnoses were recorded: 19 secondary (38%), 26 latent (52%), and 5 tertiary/neurosyphilis (12%). Syphilitic hepatitis was found in 5/50 (10%) patients. This finding supports the importance of including syphilis in the differential diagnosis of liver enzyme abnormalities in HIV-infected patients. An early diagnosis of syphilitic hepatitis can lead to rapid normalization of liver function following appropriate therapy, prevents the progression of syphilis, and limits the further spread of sexually transmitted diseases, including HIV.

Liver involvement in HIV-infected patients with early syphilis

The aim of the paper is to analyse the prevalence of liver involvement and related factors in HIV-infected patients with early syphilis (<2 years). Liver involvement was defined as an elevation above normal ranges of alanine transaminase, aspartate aminotransferase, gamma-glutamyltransferase and/or alkaline phosphatase during early syphilis, or doubling of previous levels in patients with liver enzyme elevation before syphilis. We undertook a multicentre study and of the 147 cases, 86.4% were men who had sex with men, and the diagnoses of syphilis and HIV infection were coincident in 48 (32.7%). Liver involvement was detected in 45 (30.6%) and the only related factor was a rapid plasma reagin (RPR) titre ≥1/64 (odds ratio 3.76; 95% confidence interval 1.3-10.5; P = 0.012). In conclusion, liver involvement occurs in around one-third of HIV-infected patients with early syphilis and is associated with high RPR levels. Syphilis should be included in the differential diagnosis of liver enzyme elevation in HIV-infected patients.

Systemic causes of cholestasis

Systemic causes of cholestasis constitute a diverse group of diseases across organ systems. The pathophysiology of cholestasis in systemic disease can be a consequence of direct involvement of a disease process within the liver or extrahepatic biliary system or secondary to immune-mediated changes in bile flow. Evaluating a patient with cholestasis for a systemic cause requires an understanding of the patient's risk factors, clinical setting (eg, hospitalized or immunosuppressed patient), clinical features, and pattern of laboratory abnormalities.

Prevalence of hepatitis in early syphilis among an HIV cohort

To investigate the prevalence of syphilitic hepatitis among a group of HIV-infected patients we performed a cross-sectional observational study of consecutive HIV-infected patients with early syphilis attending University Hospital Birmingham between 1 January 2005 and 31 August 2008. The AIDS Clinical Trials Group grading for abnormal liver enzymes was used to identify hepatitis. A total of 62 HIV-infected patients were diagnosed with early syphilis during the study period. Twelve (19.3%) of them demonstrated abnormal liver enzymes consistent with syphilitic hepatitis involving raised levels of alanine aminotransferase, aspartate transaminase, alkaline phosphatase or gamma-glutamyl transferase (GGT). Grade 3 hepatotoxicity was observed among five patients. None of the patients with syphilitic hepatitis had grade IV hepatitis or abnormal bilirubin levels. Liver biopsy was not carried out in any of the patients, and following completion of treatment of syphilis all abnormal liver enzymes returned to normal levels after a median of 16 weeks. Exclusion of syphilis must be considered when investigating hepatic disease in HIV-infected patients.

Liver dysfunction in patients with early syphilis: a retrospective study

Syphilis is one of the unrecognized etiologies of liver dysfunction. The incidence of syphilitic hepatitis is currently unknown. We conducted a retrospective study of causative agents of liver dysfunction at the time of diagnosis of early syphilis. Our study shows that 39 % (44/112) of early syphilis patients have liver enzyme abnormalities at the time of diagnosis and that 2.7 % (3/112) of patients are diagnosed with syphilitic hepatitis. Clinicians should include syphilitic hepatitis in the differential diagnosis for those patients with sexually transmitted diseases presenting with liver enzyme abnormalities.

Asymptomatic transmission of Treponema pallidum (syphilis) through deceased donor liver transplantation

A 55-year-old woman underwent liver transplantation (LT) with a graft from a deceased donor. Mandatory pre-donation investigations showed positive syphilis serology that was available only after the transplant, with high Treponema pallidum particle agglutination assay titer compatible with donor syphilis infection. Despite the institution of appropriate post-exposure prophylaxis, the recipient demonstrated latent seroconversion; however, liver graft function improved without evidence of syphilitic hepatitis or other manifestations of the disease. Through this first reported case of asymptomatic transmission of syphilis following LT, we highlight the investigations and treatment strategies for donor-derived syphilis in liver transplant recipients. This report supplements the existing limited evidence on safe use of infected grafts from syphilitic donors through appropriate post-exposure prophylaxis.

Liver involvement in HIV-infected patients diagnosed with syphilis

PURPOSE

Liver involvement in syphilis has been studied in cohorts of human immunodeficiency virus (HIV)-negative individuals despite the scarcity of data on such HIV-infected patients. Th aim of this study was to assess hepatic involvement of HIV-infected patients diagnosed with syphilis.

METHODS

Patients with syphilis and liver involvement, including all stages of syphilis, were systematically identified in our HIV cohort between 2004 and 2008.

RESULTS

Of the 1,599 HIV-infected patients identified during the study period, 100 were diagnosed with acute syphilis, all of whom were male. Of these 100 patients, 84% were men who have sex with men. Laboratory parameters of liver involvement were present in 19 of the 100 HIV-infected patients with syphilis; these resolved after successful antibiotic treatment. Among these 19 patients, six were diagnosed to be in the latent stage, with elevated liver enzymes and parameters of inflammation representing the only distinctive feature.

CONCLUSIONS

Based on our results, syphilis should be included in the differential diagnosis of increased liver enzymes in HIV-infected patients.

Case of secondary syphilis presenting with unusual complications: syphilitic proctitis, gastritis, and hepatitis

We report the first known case of syphilis with simultaneous manifestations of proctitis, gastritis, and hepatitis. The diagnosis of syphilitic proctitis and gastritis was established by the demonstration of spirochetes with anti-Treponema pallidum antibody staining in biopsy specimens. Unusual manifestations of secondary syphilis completely resolved after 4 weeks of antibiotic therapy.

Primary human immunodeficiency virus infection presenting as elevated aminotransferases

BACKGROUND/PURPOSE

Primary human immunodeficiency virus type 1 (HIV-1) infection is often under-diagnosed because of its nonspecific presentations. Elevated aminotransferase levels is one of its clinical manifestations, but is infrequently reported in the literature. The objective of this study was to investigate cases of elevated aminotransferases as a manifestation of primary HIV-1 infection.

METHODS

A retrospective chart review from October 1990 to May 2009 of HIV-1 infected patients in a registered database at a tertiary hospital was conducted to identify patients diagnosed with primary HIV-1 infection. An elevated aminotransferase level was broadly defined as above-normal values of alanine or aspartate aminotransferases. Acute hepatitis markers were determined using stored serum samples.

RESULTS

Twenty-three of the 827 (2.8%) patients were identified as having a primary HIV-1 infection. All were male, with a median age of 26 years (range, 19-77 years), and the majority were men who had sex with men (19/23, 82.6%). The most common clinical manifestations were fever (95.7%), elevated aminotransferases (65.2%), fatigue (47.8%), and pharyngitis (47.8%). The median CD4 lymphocyte count was 374/μL (range, 109-674/μL) and the median log HIV viral load was 5.0 (range, 4.3-5.9). For the 15 patients with abnormal liver function tests, the median aspartate aminotransferase level was 112 U/L (range, 62-969 U/L) and the median alanine aminotransferase level was 146 U/L (range, 42-1,110 U/L).

CONCLUSION

Elevated aminotransferases may be an initial manifestation of primary HIV infection and is more common than expected. Primary HIV-1 infection should be one of the differential diagnoses considered in young men presenting with unexplained, new-onset liver function impairment.

Cholestatic hepatitis and thrombocytosis in a secondary syphilis patient

The incidence of acute hepatitis in syphilis patient is rare. First of all, our patient presented with hepatitis comorbid with thrombocytosis. To our knowledge, this is only the second report of syphilitic hepatitis with thrombocytosis. The 42-yr-old male complained of flu-like symptoms and skin eruptions on his palms and soles. Laboratory findings suggested an acute hepatitis and thrombocytosis. Serologic test results were positive for VDRL. He recovered from his symptoms and elevated liver related enzymes with treatment. Because syphilitic hepatitis can present without any typical signs of accompanying syphilis, syphilis should be considered as a possible cause in acute hepatitis patients.

Syphilis: an important cause of infectious hepatitis

The UK incidence of infectious syphilis has risen sharply over the last 10 years; however, its diagnosis can be overlooked in patients who fail to disclose risk factors for its acquisition. This patient presented with hepatitis as part of a multisystemic illness and was investigated extensively before being diagnosed with secondary syphilis. The delay to diagnosis and treatment resulted in irreversible disablement. Syphilis should be considered in the differential diagnosis of hepatitis of uncertain aetiology. In addition, due to the similar presentation and risk factors for acquisition, we suggest that syphilis serology should be performed concomitant to all HIV tests, particularly those from outside the genitourinary medicine clinic setting.

A case of syphilis presenting with initial syphilitic hepatitis and serological recurrence with cerebrospinal abnormality

We present the case of an immunocompetent 50-year-old Japanese man with a cerebrospinal fluid (CSF) abnormality relevant to syphilis; his original presentation was liver dysfunction, the etiology of which was uncertain until positive serology for syphilis was identified. Liver dysfunction was promptly resolved after oral penicillin therapy; however, serological recurrence developed. CSF abnormality associated with syphilis was confirmed by subsequent lumbar puncture. Syphilis should be included in the differential diagnosis of patients with liver dysfunction of unknown etiology, and possible neurosyphilis should be considered when the treatment becomes refractory, even when there is no evidence of neurological manifestations.

Syphilitic hepatitis among HIV-infected patients

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.

Early syphilitic hepatitis in an immunocompetent patient: really so uncommon?

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.

Hépatite à syphilis et transplantation hépatique

We report a case of secondary syphilis hepatitis in a liver-transplant patient. This homosexual male patient presented, 15 years after orthotopic liver transplantation, with non-squamous papulomacular rash, mild cytolysis, and anicteric cholestasis. Laboratory tests showed syphilis seroconversion with a venereal diseases research laboratory (VDRL) titer of 1/256, a Treponema pallidum hemaglutination assay (TPHA) of 1/5120, and a positive IgM fluorescent Treponemal antibody absorbance (FTA-abs). A liver biopsy performed 13 months after the diagnosis showed low-grade hepatitis with a Metavir score of A1F1; it also showed non-specific portal moderate inflammation consisting primarily of neutrophils, with no evidence of cholestasis. He was given benzathine-penicillin at 2,400,000 IU with a transient increase in prednisolone doses. Cytolysis rapidly, and cholestasis progressively disappeared. IgM FTA-abs became negative, whereas VDRL and TPHA titers decreased slightly over time.

Biological basis for syphilis

Syphilis is a chronic sexually transmitted disease caused by Treponema pallidum subsp. pallidum. Clinical manifestations separate the disease into stages; late stages of disease are now uncommon compared to the preantibiotic era. T. pallidum has an unusually small genome and lacks genes that encode many metabolic functions and classical virulence factors. The organism is extremely sensitive to environmental conditions and has not been continuously cultivated in vitro. Nonetheless, T. pallidum is highly infectious and survives for decades in the untreated host. Early syphilis lesions result from the host's immune response to the treponemes. Bacterial clearance and resolution of early lesions results from a delayed hypersensitivity response, although some organisms escape to cause persistent infection. One factor contributing to T. pallidum's chronicity is the paucity of integral outer membrane proteins, rendering intact organisms virtually invisible to the immune system. Antigenic variation of TprK, a putative surface-exposed protein, is likely to contribute to immune evasion. T. pallidum remains exquisitely sensitive to penicillin, but macrolide resistance has recently been identified in a number of geographic regions. The development of a syphilis vaccine, thus far elusive, would have a significant positive impact on global health.