Syphilitic hepatitis: a case report and review of the literature

"Syphilitic Hepatitis": A Comprehensive Review of Clinical Features, Diagnostic Approaches, and Management Considerations

Syphilitic hepatitis is a very rare presentation of syphilis infection, characterized by inflammation of the liver due to the invasion of hepatic tissue by the bacterium Treponema pallidum. This review article provides an in-depth analysis of the existing body of information pertaining to syphilitic hepatitis. The article primarily concentrates on key aspects such as the epidemiology, clinical manifestations, diagnostic methods, and therapeutic approaches associated with this condition. Despite its rarity, awareness of syphilitic hepatitis is vital for accurate diagnosis and appropriate intervention. The clinical presentations frequently exhibit similarities with many liver illnesses, hence presenting difficulties in making an accurate diagnosis. Common symptoms include fatigue, stomach pain, and jaundice. Diagnostic procedures encompass the use of serological assays, including rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-ABS), in conjunction with imaging modalities to evaluate hepatic engagement. The primary therapeutic approach is the prompt initiation of antibiotic therapy, with a particular emphasis on penicillin, to eradicate the causative bacterial infection and facilitate the restoration of liver function. Failure to swiftly manage this condition may result in substantial morbidity. In summary, syphilitic hepatitis is a very uncommon but medically relevant manifestation of syphilis infection. The significance of increased clinical suspicion, precise diagnostic techniques, and prompt antibiotic administration is emphasized in this review since these are crucial in reducing the potentially severe outcomes associated with this illness.

Gastroenterology healthcare in LGBTQ+ individuals

Lesbian, gay, bisexual, transgender, queer, or questioning individuals, as well as those with another diverse identity (LGBTQ+), present specific nuances in healthcare that physicians must consider in clinical practice. Particularly, gastroenterologists are nowadays facing different issues in several fields regarding LGBTQ+ healthcare, such as endoscopy, inflammatory bowel disease, hepatology, and proctology. In this study, the authors provide a practice-oriented and up-to-date review reinforcing the importance of some of the most prevalent pathologies associated with sexuality that gastroenterologists may encounter in their clinical practice. In terms of endoscopy, authors describe the endoscopic findings related to human papillomavirus (HPV) infection: the esophageal squamous papilloma and cell carcinoma; also highlight the importance of retroflexion maneuver during a routine colonoscopy that allows detection of anal intraepithelial neoplasia lesions that can be anal cancer precursors. Regarding inflammatory bowel disease, some considerations are made about the differential diagnosis with infectious proctitis, and the topic of the risk of anal cancer due to HPV infection, in this specific population, is also addressed. Considering hepatology, the authors review the most important issues related to hepatotropic sexually transmitted infections. The authors also make some comments regarding the possibility of drug-induced liver injury in gender-affirming hormone therapy and pre-exposure prophylaxis for HIV prevention. Finally, considering the proctology field, an up-to-date review is performed regarding anal cancer screening, HPV infection and related diseases, and infectious proctitis management.

A Rare Case of Widely Disseminated Syphilis

Abstract is missing (Short communication)

The Great Mimicker Gets Caught: A Rare Case of Syphilis in the Gastrointestinal Tract

Syphilis is a sexually transmitted disease that impacts multiple organ systems and can mimic various diseases and is an extremely rare cause of proctitis in men who have sex with men and transgender females. We present a case of a 49-year-old transgender female with a medical history significant for diabetes mellitus and hyperlipidemia who presented to the emergency department with dull abdominal pain in the left upper and lower quadrants for two days. She had non-bloody, nonbilious emesis, 10-pound weight loss over 1 month, and constipation for 2 weeks. Laboratory results showed a cholestatic pattern. Computed tomography of the abdomen showed rectal wall thickening, multiple enlarged perirectal adenopathy, and mild inflammatory infiltration around the rectum suggesting superimposed proctitis. On colonoscopy, a possible rectal mass or severe proctitis with near complete obstruction was seen with initial pathology concerning for lymphoma or a rare type of colitis. The patient was empirically started on ceftriaxone and doxycycline leading to improvement in inflammation. Special stains requested were positive for Treponema pallidum confirming the diagnosis of syphilitic proctitis and highly suggestive syphilitic hepatitis. Few cases of syphilitic proctitis imitating rectal malignancy and syphilitic hepatitis have been reported. Syphilis requires exclusion as well as confirmation of spirochetes for high-risk populations with special staining. It is important to diagnose syphilis in special populations that are at high risk of contraction.

Making a Comeback: Syphilitic Hepatitis in a Patient with Late Latent Syphilis-Case Report and Review of the Literature

Treponema pallidum infection has emerged in recent years as an important community threat and burden to the health care system. Here, we report the case of a patient with cholestatic liver disease secondary to late latent syphilis. A 41 year-old male patient was referred to the clinic for assessment of an abnormal liver function panel. Ultrasound of the abdomen demonstrated an intense liver echogenicity, normal bile ducts, and no ascites. Virologic study revealed negative results for antibodies against common viral hepatitis and metabolic and autoimmune disease. The patient was tested for syphilis and a positive result was reported. The patient was diagnosed with late latent syphilis and syphilitic hepatitis and initiated benzathine penicillin at G 7.2 million units total, delivered as three doses of 2.4 million units intramuscular each at one-week intervals. He was assessed monthly and by the end of the sixth month, he had nonreactive VDRL (seroconversion), which confirmed recovery. Syphilitic hepatitis is an overlooked type of hepatitis and should be kept in mind as a differential diagnosis in an abnormal liver panel of uncertain etiology. Health care providers should be advised that higher levels of ALP may be the single landmark in cases of syphilitic hepatitis.

Cholestatic Liver Injury in a Patient with Tertiary Syphilis

Syphilis is a common infection that has variable presentations. We report a rare case of a 64-year-old male with 3 weeks of abdominal pain, back pain, and neurologic deficits including memory impairment who was found to have neurosyphilis causing a cholestatic liver injury. Workup included a positive rapid plasma reagin (RPR) and enzyme immunoassay (EIA), a positive cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL), and a liver biopsy, which was compatible with a diagnosis of syphilitic hepatitis. Completion of a 14-day course of penicillin and 1 month of physical therapy resulted in near full-functional and biochemical recovery.

Hepatic Secondary Syphilis Can Cause a Variety of Histologic Patterns and May Be Negative for Treponeme Immunohistochemistry

The rate of syphilis in the United States has been increasing steadily in the past decade, but it remains an uncommon diagnosis in tissue biopsies. Most of the pathology literature on hepatic syphilis consists of older series or case reports. This study aimed to systematically characterize the histologic spectrum of hepatic syphilis in a contemporary cohort. Clinicopathologic features of 14 hepatic syphilis cases between 2012 and 2018 were analyzed to characterize the broad spectrum of histologic changes. Thirteen patients were men (age range: 19 to 59 y); 6 had known human immunodeficiency virus, 7 were men known to have sex with men, and no patient had known prior syphilis. Hepatic syphilis was the primary clinical suspicion in only 1 patient. Common symptoms included jaundice, rash, and abdominal pain. Thirteen had elevated transaminases, and 12 had elevated alkaline phosphatase. Pathologic changes were grouped into 5 histologic patterns: biliary-pattern injury (n=5), acute hepatitis (n=4), autoimmune hepatitis-like (n=1), fibroinflammatory mass-forming lesion (n=2), and no particular pattern (n=2). Nearly all showed portal and lobular lymphocytes and plasma cells; 12 had prominent histiocytes/Kupffer cells, 9 had ductular reaction, and 7 had duct inflammation. Occasional focal findings included dropout (n=7), phlebitis (n=7), and loose granulomata (n=5). Treponeme immunohistochemistry was positive in 10 and negative in 4, though treatment was given before biopsy in 3 of those 4. Thirteen patients had rapid plasma reagin testing either before or after biopsy, with 1:64 or higher titer. All patients who received treatment recovered. Hepatic syphilis is rare but likely underrecognized. It exhibits a variety of histologic appearances and therefore should be considered in several hepatic differential diagnoses, especially in men who have sex with men. Kupffer cells, granulomata, and phlebitis may suggest the diagnosis regardless of predominant histologic pattern. Negative treponeme immunohistochemical staining does not exclude the diagnosis, including in untreated patients.

When the Sailor’s Handshake Fails: A Case of Syphilitic Hepatitis in an HIV Patient With Nonspecific Liver Biopsy and Atypical Cutaneous Presentation

Secondary syphilis has variable systemic manifestations, impersonating the presentation of more common pathologies, deceiving clinicians, and creating a difficult-to-diagnose patient. The case discussed combines hepatic syphilis with an uncommon syphilitic dermatologic presentation in a patient with HIV and a history of hepatitis A and B. Due to the challenge of diagnosis, the relative ease of confirming the diagnosis with serological assays, and reversibility of hepatic injury, the inclusion of syphilitic hepatitis on a differential diagnosis of hepatitis is warranted.

Autoimmune Hepatitis Induced after Treatment of Syphilitic Hepatitis

We present a unique case of biopsy-proven syphilitic hepatitis which presented as severe acute liver injury with significant elevation in aminotransferases and bilirubin, and improved with antibiotic therapy. However, the patient returned weeks after initial presentation with new-onset acute liver injury and had developed hypergammaglobulinemia, positive autoantibody titers, and repeat liver biopsy demonstrating interface hepatitis, supporting a diagnosis of autoimmune hepatitis. He had an otherwise unrevealing etiologic workup, and responded to glucocorticoid therapy. We believe that syphilitic hepatitis and its treatment subsequently triggered an immunogenic response, leading to autoimmune hepatitis. Autoimmune hepatitis is a chronic liver disease thought to manifest as a result of predisposing genetic factors in combination with environmental insults, especially hepatotropic pathogens. Syphilis is a sexually transmitted disease caused by Treponema pallidum that has been associated with autoimmunity and the development of autoantibodies. We propose that in the setting of syphilitic hepatitis, a molecular mimicry event resulting from structural similarities between T. pallidum and liver antigens, as well as impaired regulatory T-cell function, led to the breakdown of immune tolerance and the onset of autoimmune hepatitis. To support this hypothesis, further molecular analyses and case series are necessary to determine if syphilitic hepatitis and its treatment are risk factors for the onset of autoimmune hepatitis. Autoimmune hepatitis should be considered early as the cause of acute liver injury in susceptible patients with risk factors for the disease, as prompt recognition and appropriate treatment may prevent progression of liver injury and result in improved outcomes.

Case Report: Syphilitic Hepatitis-A Rare and Underrecognized Etiology of Liver Disease With Potential for Misdiagnosis

Syphilitic hepatitis (SH) in adults is a rare condition that can be easily misdiagnosed. Clinical and histopathologic manifestations of SH can mimic other infectious and non-infectious conditions, and the diagnosis should be considered in all at-risk patients with abnormal liver function tests. We present an unusual case of SH presenting with seizures and multiple liver lesions. This case report, in line with other newly published reports, promotes awareness of SH as a rare manifestation of treponemal infection and highlights the importance of including SH in the differential diagnosis for patients at risk for sexually transmitted infections and presenting with liver enzyme abnormalities. From a hospital quality control and socioeconomic perspective, our case adds to the growing body of evidence that demonstrates an increasing incidence of patients suffering from venereal diseases and injection drug use disorders, and the burden these conditions place on the healthcare system. Recognition of the clinicopathologic features of SH is required to prevent missed diagnosis and to foster systematic crosstalk between healthcare staff and public health personnel managing this problem.

An Unusual Case of Syphilis With Abdominal Pain

Syphilis is a multisystem infection caused by Treponema pallidum, a common sexually transmitted bacterium. The different stages and associated signs of syphilis are well characterized. We present an atypical case of syphilis in a 27-year-old female with hepatitis and gastritis. The diagnostic criteria for syphilitic hepatitis and gastritis are discussed here, along with endoscopic and clinical findings, treatment, and a brief literature review.

Syphilitic Hepatitis: A Rare Cause of Acute Liver Injury

Syphilitic hepatitis represents a rare manifestation of treponemal infection. Diagnosis is achieved with the presence of characteristic syphilitic signs and symptoms along with positive serological markers, characteristic elevated liver enzymes, and no other alternative cause of hepatobiliary insult. Here we detail a case of a patient presenting with recently diagnosed secondary syphilis causing abnormal liver enzymes. With the increasing incidence of venereal diseases in the United States, this case highlights the importance of identifying syphilis as a differential diagnosis for acute liver injury.

Syphilis Hepatitis Presenting as a Mimic of Primary Biliary Cholangitis

Syphilis hepatitis is a rare cause of acute liver injury. Primary biliary cholangitis (PBC) is a progressive autoimmune disease characterized by the typical presentation of a cholestatic liver injury and the presence of antimitochondrial antibodies (AMAs). We present a case of syphilis hepatitis that presented as a mimic to PBC with positive AMA. The eradication of syphilis led to the resolution of the liver injury and down trending of the antibody level. We recommend excluding syphilis in patients with high-risk behaviors presenting with a cholestatic liver injury and positive AMA before the diagnosis of PBC.

Authors response to correspondence regarding paper entitled Syphilitic hepatitis: a case report and review of the literature

In the correspondence from Abdurrahman et al., they raised three main concerns and critiques of our recently published article entitled “Syphilitic hepatitis: a case report and review of the literature”. First question pertains to the timing of dermatology opinion, second regarding the history of sexual exposure, and lastly regarding the treatment duration of syphilitic hepatitis. We thank the authors for their constructive comments and would like to answer these questions in detail.

Management of syphilitic hepatitis

Syphilis is a sexuality transmitted disease caused by Treponema pallidum. Liver involvement is very rarely seen and occurs in the second phase of the disease. Syphilitic hepatitis generally is mild clinical condition and is characterized by high serum alkaline phosphatase level, often with normal or only slightly abnormal transaminases. The skin eruptions are classically diffuse, symmetric maculopapular rashes involving trunk and extremities. Involvement of palms and soles is a strong clue to the diagnosis of secondary syphilis. Therefore, syphilitic hepatitis should be included in the early differential diagnosis in patient with abnormal liver enzyme, especially increased alkaline phosphatase, and rashes involving palms and soles.