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Coelho R, Gonçalves R, Mendes F, Macedo G. Gastroenterology healthcare in LGBTQ+ individuals. Eur J Gastroenterol Hepatol 2024; 36:1059-1067. [PMID: 38916210 DOI: 10.1097/meg.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
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.
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Affiliation(s)
- Rosa Coelho
- Gastroenterology Department, Centro Hospitalar Universitário de São João
- Gastroenterology Department, World Gastroenterology Organization Training Center
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Raquel Gonçalves
- Gastroenterology Department, Centro Hospitalar Universitário de São João
- Gastroenterology Department, World Gastroenterology Organization Training Center
| | - Francisco Mendes
- Gastroenterology Department, Centro Hospitalar Universitário de São João
- Gastroenterology Department, World Gastroenterology Organization Training Center
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar Universitário de São João
- Gastroenterology Department, World Gastroenterology Organization Training Center
- Faculty of Medicine, University of Porto, Porto, Portugal
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Goyal MK, Dhaliwal KK, Agrawal S. "Syphilitic Hepatitis": A Comprehensive Review of Clinical Features, Diagnostic Approaches, and Management Considerations. J Clin Gastroenterol 2024; 58:635-639. [PMID: 38896421 DOI: 10.1097/mcg.0000000000002035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
- Manjeet Kumar Goyal
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | | | - Sangeeta Agrawal
- Medicine, Wright State University, Dayton VA Medical Center, Dayton, OH
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3
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Slyk A, Hedman M, Wikström A. A Rare Case of Widely Disseminated Syphilis. Acta Derm Venereol 2024; 104:adv27983. [PMID: 38813741 PMCID: PMC11161808 DOI: 10.2340/actadv.v104.27983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/22/2024] [Indexed: 05/31/2024] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Agnieszka Slyk
- Department of Dermatology and Venereology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Hedman
- Department of Dermatology and Venereology, Karolinska University Hospital, Stockholm, Sweden
| | - Arne Wikström
- Department of Dermatology and Venereology, Karolinska University Hospital, Stockholm, Sweden
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4
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Kaufman R, Sanchez JM, Amer R. The Great Imitator Masquerading as Autoimmune Hepatitis and Demystifying as Fulminant Syphilitic Retinitis. Ocul Immunol Inflamm 2024:1-5. [PMID: 38669600 DOI: 10.1080/09273948.2024.2345290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
PURPOSE Syphilis is a "Great Masquerader" because of its versatile clinical manifestations. We aim to report a patient whose first presentation was with presumed autoimmune hepatitis. Fulminant retinitis subsequently ensued, thus enabling correct diagnosis and treatment. METHODS Case description. RESULTS A 62-year-old male presented with bilateral drop in vision. One month earlier, right eye (RE) arteritic ischemic optic neuropathy was suspected because of severe headache, sudden drop in vision, relative afferent pupillary defect, and elevated inflammatory markers. Systemic steroids were instituted. Brain imaging and temporal artery biopsy were unyielding. Four months earlier, liver biopsy performed because of elevated cholestatic liver enzymes, revealed granulomatous hepatitis. After ruling out viral hepatitis, autoimmune etiology was presumed, and prednisone was started. On presentation, visual acuity (VA) was counting fingers in RE and 6/20 in the left eye (LE). Bilateral panuveitis with punctate inner retinitis, placoid chorioretinitis was diagnosed. Serological tests were strongly positive for syphilis. Lumbar puncture confirmed the existence of neurosyphilis. Systemic penicillin was initiated. One month later, VA improved to RE 6/10, LE 6/7.5, with marked resolution of posterior uveitis. No recurrence was observed over 27-month-period. CONCLUSION Acquired syphilitic hepatitis is rarely reported. Administering steroids potentially aggravated the infection. The characteristic features of placoid chorioretinitis and punctate inner retinitis connected the pieces of the puzzle together to the diagnosis of ocular and neurosyphilis. Intrahepatic cholestasis with negative serological panel of hepatotropic pathogens should raise the suspicion of non-hepatotropic pathogens especially syphilis.
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Affiliation(s)
- Ron Kaufman
- Department of Ophthalmology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Juan Martin Sanchez
- Department of Ophthalmology, Hadassah Medical Organization, Jerusalem, Israel
| | - Radgonde Amer
- Department of Ophthalmology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Cantu Lopez C, Herrera-Gonzalez S, Shamoon D, Dacosta TJ, Bains Y. The Great Mimicker Gets Caught: A Rare Case of Syphilis in the Gastrointestinal Tract. Cureus 2024; 16:e59222. [PMID: 38807842 PMCID: PMC11132664 DOI: 10.7759/cureus.59222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2024] [Indexed: 05/30/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - Dema Shamoon
- Gastroenterology and Hepatology, Saint Michael's Medical Center, Newark, USA
| | - Theodore Jr Dacosta
- Gastroenterology and Hepatology, Saint Michael's Medical Center, Newark, USA
| | - Yatinder Bains
- Gastroenterology and Hepatology, Saint Michael's Medical Center, Newark, USA
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Yilmaz K, Fahimi S, Huebers C, Géraud C. Der große Imitator: Sekundäre Syphilis unter dem klinischen Bild einer Psoriasis palmoplantaris: The great impostor: Secondary syphilis imitating palmoplantar psoriasis. J Dtsch Dermatol Ges 2024; 22:442-445. [PMID: 38450893 DOI: 10.1111/ddg.15316_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/30/2023] [Indexed: 03/08/2024]
Affiliation(s)
- Kaan Yilmaz
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Mannheim und Medizinische Fakultät Mannheim der Ruprecht-Karls-Universität Heidelberg
| | - Sarah Fahimi
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Mannheim und Medizinische Fakultät Mannheim der Ruprecht-Karls-Universität Heidelberg
| | - Corinne Huebers
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Mannheim und Medizinische Fakultät Mannheim der Ruprecht-Karls-Universität Heidelberg
| | - Cyrill Géraud
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Mannheim und Medizinische Fakultät Mannheim der Ruprecht-Karls-Universität Heidelberg
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7
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Yilmaz K, Fahimi S, Huebers C, Géraud C. The great impostor: Secondary syphilis imitating palmoplantar psoriasis. J Dtsch Dermatol Ges 2024; 22:442-445. [PMID: 38279546 DOI: 10.1111/ddg.15316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/30/2023] [Indexed: 01/28/2024]
Affiliation(s)
- Kaan Yilmaz
- Department of Dermatology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sarah Fahimi
- Department of Dermatology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Corinne Huebers
- Department of Dermatology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Cyrill Géraud
- Department of Dermatology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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8
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Supronowicz Ł, Rogalska M. Syphilitic hepatitis. Clin Exp Hepatol 2024; 10:9-13. [PMID: 38765910 PMCID: PMC11100338 DOI: 10.5114/ceh.2024.136235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/16/2023] [Indexed: 05/22/2024] Open
Abstract
Syphilis is a sexually transmitted multisystemic disease known as "the great imitator" due to its variable presentations. Despite being preventable and curable, it still constitutes a major health problem. Hepatic manifestation of syphilis is usually mild cholestatic liver injury but in very rare cases can become fulminant. Moreover, syphilitic hepatitis, known for several decades, is considered rare but is probably under-diagnosed. Given the significant morbidity associated with a missed diagnosis, syphilitic hepatitis should be taken into account as an element of differential diagnosis in patients with unexplained elevation of liver enzymes.
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Affiliation(s)
- Łukasz Supronowicz
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, Poland
| | - Magdalena Rogalska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, Poland
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9
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Chen T, Wan B, Wang M, Lin S, Wu Y, Huang J. Evaluating the global, regional, and national impact of syphilis: results from the global burden of disease study 2019. Sci Rep 2023; 13:11386. [PMID: 37452074 PMCID: PMC10349077 DOI: 10.1038/s41598-023-38294-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
Syphilis is a global public health concern. This study aimed to assess the global and regional burden of syphilis from 1990 to 2019. Disease burden was evaluated using disability-adjusted life-years (DALYs) and prevalence. Data were extracted from the 2019 global burden of disease Study, an open database available for download. Age-standardized rates (ASR) and estimated annual percentage changes (EAPC) were calculated to evaluate the syphilis burden over time. In 2019, the total number of prevalent cases of syphilis was 49.71 million worldwide. The ASR of prevalence was stable from 1990 to 2019 with an EAPC of 0.00 (95% CI - 0.10-0.11). The number of DALYs caused by syphilis was 7.36 million in 2019, reflecting a reduction of 16.38% compared with that in 1990 (8.80 million). The ASR of DALYs exhibited a decreasing trend from 1990 to 2019 (EAPC = - 1.01; 95% CI - 1.19 to - 0.84), with the highest rates observed in the younger age group (< 14 years old). In 2019, the highest ASR of DALYs was found in low sociodemographic index (SDI) regions (239.21/100,000), and the lowest in high SDI regions (3.14/100,000). Generally, the ASR of DALYs decreased as the SDI increased. The top three countries with the highest ASR of DALYs for syphilis were the Solomon Islands, Equatorial Guinea, and Liberia. While the global prevalence of syphilis remained persistently high from 1990 to 2019, there has been a recent decrease in the ASR of DALYs. Increased attention should be dedicated to younger populations and regions characterized by low SDIs.
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Affiliation(s)
- Tao Chen
- The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Bo Wan
- The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mingfang Wang
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian, China
- Fujian Clinical Research Center for Liver and Intestinal Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Hepatology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian, China
- Fujian Clinical Research Center for Liver and Intestinal Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Hepatology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yinlian Wu
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian, China
- Fujian Clinical Research Center for Liver and Intestinal Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Hepatology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jiaofeng Huang
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian, China.
- Fujian Clinical Research Center for Liver and Intestinal Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China.
- Department of Hepatology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China.
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10
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Orozco-Sebá BE, Viasus D, Meléndez E, Fuentes J, Tovar J, Amado EA, Loaiza D. Intrahepatic cholestasis due to Treponema pallidum in an immunocompetent patient. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:164-170. [PMID: 37433168 PMCID: PMC10513144 DOI: 10.7705/biomedica.6630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 05/11/2023] [Indexed: 07/13/2023]
Abstract
Hepatitis due to Treponema pallidum is a rare entity and its diagnosis represents a clinical challenge. Treponema pallidum should be considered as a presumptive etiology in all patients with acute liver disease, when other frequent causes have been ruled out. We present the case of a young, immunocompetent patient with elevated values in his liver tests, a cholestatic pattern, and maculopapular lesions on his palms and soles. Given his clinical picture, diagnostic tests, and response to the antimicrobial therapy, a diagnosis of cholestasis due to secondary syphilis has been established. It is important to include secondary syphilis within the possible causes of acute liver disease.
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Affiliation(s)
- Beatriz E Orozco-Sebá
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Diego Viasus
- División de Ciencias de la Salud, Facultad de Medicina, Hospital Universidad del Norte de Barranquilla, Universidad del Norte, Barranquilla, Colombi.
| | - Esperanza Meléndez
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Jairo Fuentes
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - José Tovar
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Elkin A Amado
- División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Daniela Loaiza
- División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
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11
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Mullally D, Kotha S, Mandour MO, Berry P. Luetic (syphilitic) hepatitis: the great imitator persists in the 21st century. BMJ Case Rep 2023; 16:e254330. [PMID: 37160377 PMCID: PMC10174013 DOI: 10.1136/bcr-2022-254330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
A male patient in his 20s was referred to the hepatology team with jaundice, pruritus and drenching night sweats. Investigations revealed an acute hepatitis with negative autoimmune and viral serology. Liver biopsy demonstrated severe pan-lobular hepatitis, and an extended diagnostic screen included a positive treponemal antibody test, with an RPR titre of 64, indicating active syphilis infection. He was treated with 2.4 million units of intramuscular benzathine penicillin as a single dose which led to complete resolution of the abnormal liver tests and symptoms. Diagnostic and management challenges, including the role of good history taking, appropriate investigations and role of multidisciplinary team, are discussed.
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Affiliation(s)
- Daniel Mullally
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mandour Omar Mandour
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Muacevic A, Adler JR, Surani A. Syphilitic Hepatitis: A Rare Cause of Elevated Liver Function Tests. Cureus 2023; 15:e34312. [PMID: 36860232 PMCID: PMC9970300 DOI: 10.7759/cureus.34312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
Syphilitic hepatitis is a rare manifestation of syphilis with an incidence of 0.2-38%. We describe a case of a healthy, immunocompetent male patient with elevated liver function tests (LFTs) who was found to have syphilitic hepatitis. A 28-year-old male with no past medical history presented with abdominal pain for two to three weeks. He also reported diminished appetite, intermittent chills, weight loss, and fatigue. His history was positive for high-risk sexual behavior including multiple partners and absence of using protection. His physical examination was remarkable for right-sided abdominal tenderness and a painless chancre on his penile shaft. His workup revealed elevated aspartate aminotransferase (AST: 169 U/L), alanine transaminase (ALT: 271 U/L), and alkaline phosphatase (ALP: 377 U/L). His abdominal CT scan was unremarkable except for the abdominal and pelvic lymphadenopathy. A thorough serology panel revealed negative hepatitis A, B, C, human immunodeficiency virus (HIV) (including HIV RNA), Epstein-Barr virus (EBV), and cytomegalovirus (CMV). His immunological workup was negative as well. His rapid plasma reagin (RPR) was reactive with positive IgG/IgM treponemal antibodies. He was managed as secondary syphilis and received 2.4 million units of benzathine penicillin. Upon follow-up after one week, he reported a complete resolution of his symptoms, and his LFTs were normalized on a repeat checkup. Given the significant morbidity associated with a missed diagnosis, syphilitic hepatitis should be considered an essential part of the workup for evaluating elevated LFTs in an appropriate clinical setting. This case also highlights the importance of obtaining a comprehensive sexual history and performing a thorough genital examination.
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Plesa A, Gheorghe L, Hincu CE, Clim A, Nemteanu R. Making a Comeback: Syphilitic Hepatitis in a Patient with Late Latent Syphilis-Case Report and Review of the Literature. Pathogens 2022; 11:pathogens11101151. [PMID: 36297208 PMCID: PMC9608871 DOI: 10.3390/pathogens11101151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/01/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Alina Plesa
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
| | - Liliana Gheorghe
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Department of Radiology, “Sfantul Spiridon” Hospital, 700111 Iasi, Romania
- Correspondence: (L.G.); (R.N.)
| | - Corina Elena Hincu
- Department of Radiology, “Sfantul Spiridon” Hospital, 700111 Iasi, Romania
| | - Andreea Clim
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Roxana Nemteanu
- Medical I Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
- Correspondence: (L.G.); (R.N.)
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14
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Mujumdar S, Goldenberg J, Bieser S, Pang AS, Coben R. Cholestatic Liver Injury in a Patient with Tertiary Syphilis. Case Rep Gastroenterol 2022; 16:552-556. [PMID: 36824700 PMCID: PMC9941764 DOI: 10.1159/000526247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/26/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Sahaj Mujumdar
- aDepartment of Internal Medicine Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA,*Sahaj Mujumdar,
| | - Jason Goldenberg
- aDepartment of Internal Medicine Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Bieser
- bSidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alice S. Pang
- cDivision of Gastroenterology and Hepatology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert Coben
- cDivision of Gastroenterology and Hepatology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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15
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Hoffmann NV, Berken JA, Banc-Husu AM, Taylor SA, Kriegermeier A. A Case of Syphilitic Hepatitis in an Adolescent. JPGN REPORTS 2022; 3:e189. [PMID: 37168911 PMCID: PMC10158399 DOI: 10.1097/pg9.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/24/2022] [Indexed: 05/13/2023]
Abstract
The incidence of syphilis is rising among adolescents necessitating improved provider awareness and screening practices. We present a case of an adolescent with acute hepatitis ultimately diagnosed with secondary syphilitic hepatitis. Clinical presentation, laboratory abnormalities, and histologic features of syphilitic hepatitis are nonspecific, with diagnosis relying on clinical suspicion and targeted testing. This case highlights the importance of screening for syphilis in sexually active adolescents with acute hepatitis. The rising incidence of syphilis among adolescents, and the variety of clinical manifestations including those commonly seen by pediatric gastroenterologists, makes elevated clinical suspicion essential to prompt diagnosis and treatment. With improved provider awareness across general pediatric and subspecialty providers, the transmission of syphilis among adolescent patients can be reduced.
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Affiliation(s)
- Natalie V. Hoffmann
- From the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jonathan A. Berken
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anna M. Banc-Husu
- Departmart of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Sarah A. Taylor
- From the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alyssa Kriegermeier
- From the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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16
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Syphilis Presenting as Hepatitis in an HIV-Infected Patient. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Malvar G, Cardona D, Pezhouh MK, Adeyi OA, Chatterjee D, Deisch JK, Lamps LW, Misdraji J, Stueck AE, Voltaggio L, Gonzalez RS. Hepatic Secondary Syphilis Can Cause a Variety of Histologic Patterns and May Be Negative for Treponeme Immunohistochemistry. Am J Surg Pathol 2022; 46:567-575. [PMID: 34864775 DOI: 10.1097/pas.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Grace Malvar
- Beth Israel Deaconess Medical Center
- Department of Pathology, Harvard Medical School
| | - Diana Cardona
- Department of Pathology, Duke University Medical Center, Raleigh, NC
| | - Maryam K Pezhouh
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Oyedele A Adeyi
- Department of Pathology, Toronto General Hospital, Toronto, ON
| | - Deyali Chatterjee
- Department of Pathology & Immunology, Washington University, St. Louis, MO
| | - Jeremy K Deisch
- Department of Pathology and Human Anatomy, Loma Linda University Medical Center, Loma Linda, CA
| | - Laura W Lamps
- Department of Pathology, University of Michigan Hospitals, Ann Arbor, MI
| | - Joseph Misdraji
- Department of Pathology, Harvard Medical School
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Ashley E Stueck
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - Raul S Gonzalez
- Beth Israel Deaconess Medical Center
- Department of Pathology, Harvard Medical School
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18
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Ali H, Rizvi T, Niazi M, Galan M, Pyrsopoulos N. Autoimmune Hepatitis Induced after Treatment of Syphilitic Hepatitis. J Clin Transl Hepatol 2022; 10:174-177. [PMID: 35233387 PMCID: PMC8845154 DOI: 10.14218/jcth.2020.00178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/02/2021] [Accepted: 05/11/2021] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Hasan Ali
- Department of Internal Medicine, Rutgers University New Jersey Medical School, Newark, NJ, USA
- Correspondence to: Hasan Ali, Rutgers University New Jersey Medical School, Department of Medicine, University Hospital, Room I-248, 150 Bergen Street, Newark, NJ 07103, USA. ORCID: https://orcid.org/0000-0001-5726-5657. Tel: +1-732-861-5116, E-mail: ,
| | - Taqi Rizvi
- Edward Via College of Osteopathic Medicine, Spartanburg, SC, USA
| | - Mumtaz Niazi
- Division of Gastroenterology and Hepatology, Rutgers University New Jersey Medical School, Newark, NJ, USA
| | - Mark Galan
- Department of Pathology, Immunology and Laboratory Medicine, Rutgers University New Jersey Medical School, Newark, NJ, USA
| | - Nikolaos Pyrsopoulos
- Division of Gastroenterology and Hepatology, Rutgers University New Jersey Medical School, Newark, NJ, USA
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19
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Al Dallal HA, Narayanan S, Alley HF, Eiswerth MJ, Arnold FW, Martin BA, Shandiz AE. Case Report: Syphilitic Hepatitis-A Rare and Underrecognized Etiology of Liver Disease With Potential for Misdiagnosis. Front Med (Lausanne) 2021; 8:789250. [PMID: 34912834 PMCID: PMC8666961 DOI: 10.3389/fmed.2021.789250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Hiba A Al Dallal
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, United States
| | - Siddharth Narayanan
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
| | - Hanah F Alley
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Michael J Eiswerth
- Department of Internal Medicine, University of Louisville, Louisville, KY, United States
| | - Forest W Arnold
- Division of Infectious Diseases, University of Louisville, Louisville, KY, United States
| | - Brock A Martin
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, United States
| | - Alaleh E Shandiz
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, United States
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20
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Biswas U, Chandra A, Das SK, Chakraborty U, Ghosh S. Acute hepatitis as a presenting feature of secondary syphilis. J R Coll Physicians Edinb 2021; 51:382-383. [PMID: 34882140 DOI: 10.4997/jrcpe.2021.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Uttam Biswas
- Department of Internal Medicine, Burdwan Medical College and Hospital, Burdwan, India
| | - Atanu Chandra
- Doctor's Quarters (RG Kar Medical College Campus), 1 Khudiram Bose Sarani, Kolkata - 700004, West Bengal, India,
| | - Somak Kumar Das
- Department of Internal Medicine, College of Medicine and JNM Hospital, Kalyani, India
| | - Uddalak Chakraborty
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, India
| | - Shrestha Ghosh
- Department of Internal Medicine, RG Kar Medical College and Hospital, Kolkata, India
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21
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Subedi A, Hoilat G, Kumar VCS, Bhutta A, Subedi AS, Gupta A. Syphilitic hepatitis as a manifestation of secondary syphilis. Proc AMIA Symp 2021; 34:696-697. [PMID: 34732991 DOI: 10.1080/08998280.2021.1936362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Syphilis is a multisystem disease caused by the spirochete Treponema pallidum. Among various organs affected, liver involvement is seen infrequently and can be missed. Here we present a case of hepatitis due to secondary syphilis that completely resolved with penicillin G therapy.
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Affiliation(s)
- Abinash Subedi
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Gilles Hoilat
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | | | - Abdul Bhutta
- Division of Gastroenterology, SUNY Upstate Medical University, Syracuse, New York.,Division of Gastroenterology, VA Medical Center, Syracuse, New York
| | | | - Anand Gupta
- Division of Gastroenterology, VA Medical Center, Syracuse, New York
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22
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Abstract
In the United States, the incidence of new cases of syphilis has been rising. The number of cases of primary and secondary syphilis has continued to increase almost every year over the past 2 decades. Secondary syphilis has a variety of clinical manifestations. A frequently overlooked presentation is that of syphilitic hepatitis, which should be part of the differential diagnosis for patients with elevated liver enzymes, a maculopapular rash, and/or risk factors for contracting syphilis. In this study, we report a rare and unusual case of a man with a remote history of syphilis infection who developed acute liver injury.
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23
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Smale M, Connell WR, Schulberg JD. Syphilitic hepatitis: an increasingly common presentation of an epidemic disease. Med J Aust 2021; 215:190-190.e1. [PMID: 34296447 DOI: 10.5694/mja2.51191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Kabanovski A, Jeeva-Patel T, Kaplan A, Bui E, Margolin EA. Older woman with abdominal pain and bilateral sequential vision loss due to syphilis. BMJ Case Rep 2021; 14:14/6/e243847. [PMID: 34193456 DOI: 10.1136/bcr-2021-243847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 62-year-old woman presented with non-specific abdominal pain, elevated alkaline phosphatase levels and bilateral sequential visual loss. Visual acuity was counting fingers in right eye (RE) and 20/400 in left eye (LE). She was noted to have optic nerve pallor in RE and mildly elevated optic disc with signs of ocular inflammation in LE. After 2 weeks, vision deteriorated to light perception bilaterally with now extensive vitreal inflammation present in both eyes. Positive rapid plasma reagen and Treponema pallidum's antibody tites confirmed syphilis infection. Unfortunately, as the diagnosis was delayed by many months, her visual acuity remained poor (hand motions in RE and 20/50 in LE) despite treatment with intravenous penicillin. This case reminds us of the re-emergence of this 'great masquerader' and highlights the importance of maintaining high suspicion for syphilis in patients with unexplained visual loss and systemic symptoms, even in older adults without identifiable risk factors.
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Affiliation(s)
- Anna Kabanovski
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Trishal Jeeva-Patel
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Kaplan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Esther Bui
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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25
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Alemam A, Ata S, Shaikh D, Leuzzi B, Makker J. Syphilitic Hepatitis: A Rare Cause of Acute Liver Injury. Cureus 2021; 13:e14800. [PMID: 34094758 PMCID: PMC8168444 DOI: 10.7759/cureus.14800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Ahmed Alemam
- Gastroenterology, BronxCare Health System, Bronx, USA
| | - Subhan Ata
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Danial Shaikh
- Medicine/Gastroenterology, BronxCare Health System, Bronx, USA.,Internal Medicine, BronxCare Health System, Bronx, USA
| | - Bianca Leuzzi
- Gastroenterology, American University of the Caribbean, Cupecoy, SXM
| | - Jasbir Makker
- Gastroenterology, BronxCare Health System, Bronx, USA
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26
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Goldberg E, Edwards B, Krill K. Atypical case of syphilitic hepatitis. BMJ Case Rep 2021; 14:14/3/e237851. [PMID: 33731401 PMCID: PMC7978060 DOI: 10.1136/bcr-2020-237851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 31-year-old immunocompetent, heterosexual man with no relevant medical history presented with 1 week of jaundice, abdominal pain, cough and headache. Examination revealed scleral icterus, right upper quadrant tenderness and hepatomegaly. Initial investigations revealed hyperbilirubinaemia and elevated transaminases. Serum studies were positive for antinuclear antibodies, antimitochondrial antibodies, and herpes simplex virus IgM. Despite being started on intravenous acyclovir, his bilirubin and transaminase levels continued to rise. He was subsequently tested for syphilis given his maculopapular rash on the soles of his feet and it returned positive. He improved clinically with the initiation of penicillin. In this case, we will discuss the presentation, diagnosis and treatment of syphilitic hepatitis.
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Affiliation(s)
- Elliott Goldberg
- Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Bathai Edwards
- Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kaleigh Krill
- Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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27
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Pereira FG, Leal MS, Meireles D, Cavadas S. Syphilitic hepatitis; a rare manifestation of a common disease. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2021; 14:77-80. [PMID: 33868613 PMCID: PMC8035539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Syphilis is a sexual transmitted disease caused by Treponema pallidum and an underdiagnosed and underreported cause of acute hepatitis. In recent years, reported cases of primary and secondary syphilis have been increasing, mostly in men who have sex with men. Clinical manifestations of syphilis are diverse, earning the name of "the great imitator" which can affect virtually any organ. Nonetheless, hepatic involvement is rare, but it can occur at any stage of the disease. We present the case of a 41-year-old immunocompetent male, that presents to us with a cholestatic hepatitis and a diffuse erythematous rash with palmo-plantar affection. The patient had no history of primary syphilis. After throughout aetiologic study, he was diagnosed with syphilitic hepatitis and treated with intramuscular Benzathine benzylpenicillin, with the disappearance of the rash and normalization of liver enzymes after 3 months. We would like to highlight that this aetiology should be considered in patients with unexplained elevation of liver enzymes (mainly cholestatic enzymes) and an epidemiologic context of unsafe sexual exposure.
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28
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Syphilis Hepatitis Presenting as a Mimic of Primary Biliary Cholangitis. ACG Case Rep J 2020; 7:e00497. [PMID: 33324716 PMCID: PMC7725250 DOI: 10.14309/crj.0000000000000497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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29
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Huang J, Wan B, Wang M, Zhu Y, Lin S. Authors response to correspondence regarding paper entitled Syphilitic hepatitis: a case report and review of the literature. BMC Gastroenterol 2020; 20:385. [PMID: 33203372 PMCID: PMC7670659 DOI: 10.1186/s12876-020-01497-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Jiaofeng Huang
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350001, Fujian, China
| | - Bo Wan
- Faculty of Life Sciences and Medicine, King's College London, London, SE1 1UL, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mingfang Wang
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350001, Fujian, China
| | - Yueyong Zhu
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350001, Fujian, China
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350001, Fujian, China.
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30
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The Great Spiral Masquerader: A Case of Concurrent Secondary Syphilis and Autoimmune Hepatitis. ACG Case Rep J 2020; 7:e00451. [PMID: 33062789 PMCID: PMC7526711 DOI: 10.14309/crj.0000000000000451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/08/2020] [Indexed: 01/22/2023] Open
Abstract
We describe a unique case of rash and acute hepatitis confounded by the presence of syphilis that created suspicion for syphilitic hepatitis, a rare and often misdiagnosed condition. Investigation concerning the etiology alternatively lead to the diagnosis of 2 concomitant conditions: active autoimmune hepatitis and secondary syphilis. To our knowledge, this is the first description in the literature of the simultaneous occurrence of secondary syphilis and autoimmune hepatitis. This case serves to increase the recognition of the clinical characteristics and diagnostic challenges of syphilitic hepatitis and to discuss the potential role of pathogens in the induction of autoimmunity.
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31
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Prevalence of Syphilitic Hepatitis Among HIV-Infected Patients in Istanbul, Turkey, a Region with an Increasing Incidence of Syphilis and HIV Infection. HEPATITIS MONTHLY 2020. [DOI: 10.5812/hepatmon.104642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: Syphilis is a global health issue, which continues to occur at high rates worldwide, particularly in HIV-infected men, who have sex with men (MSM). Hepatitis can present as an uncommon manifestation of syphilis, and the diagnosis may be overlooked in favor of more common causes of liver injury in this group. Objectives: This study aimed to determine the prevalence and risk factors of syphilitic hepatitis among HIV-infected individuals diagnosed with acute syphilis. Methods: This cross-sectional study was conducted on HIV-infected individuals who regularly attended a tertiary clinic in Istanbul. The data were collected and analyzed between 2016 and 2019. Cases of syphilitic hepatitis were included according to the following criteria: (I) VDRL-confirmed Treponema pallidum infection after or simultaneously diagnosed with HIV infection; (II) elevated liver enzymes, including ALT, AST, and ALP, that resolved after penicillin treatment; and (III) exclusion of other causes of hepatitis. Sociodemographic characteristics of the participants, clinical and laboratory findings were evaluated using medical records. Results: Among 1,057 HIV-infected patients, 141 (13.3%) were diagnosed to have an early stage of syphilis, 138 of them were male. Nine (6.4 %) out of 141 patients had syphilitic hepatitis, and all of them were self-identified MSM. Moreover, 5 out of these 9 patients were simultaneously diagnosed with syphilis and HIV infection. Up to 10-fold increase in ALT/AST was noted in all of them, and a 3.5-fold increase in bilirubin was observed in two cases. The most prominent laboratory abnormalities in syphilitic hepatitis patients were the detection of a considerable increase in ALP and HIV RNA levels. Conclusions: Syphilitic hepatitis is not encountered rarely in HIV-infected individuals, predominantly MSM populations. Since HIV/syphilis coinfected patients are more infective as a result of higher HIV RNA levels, early diagnosis, and treatment are crucial.
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32
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Ferrándiz-Pulido C, Ferrer B, Salcedo MT, Velasco M, Len O, Castells L. Secondary syphilis with liver involvement in a liver transplant recipient. Transpl Infect Dis 2020; 23:e13431. [PMID: 32738832 DOI: 10.1111/tid.13431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 11/29/2022]
Abstract
Syphilis is capable of compromising almost any organ; however, syphilitic hepatitis is a rare manifestation that has been described most often in HIV-infected patients. Herein, we present a 33-year-old male liver transplant recipient who presented with progressive liver dysfunction characterized by mild ALT elevation and rising cholestasis, malaise, skin rash, and alopecia. Skin biopsy was characteristic of secondary syphilis, confirmed by both skin and liver biopsy-positive immunohistochemical staining for Treponema pallidum. The patient was treated with benzathine penicillin G 2.4 million units IM q week × 3 weeks. Three months later, the patient was asymptomatic and recovered from his general malaise. He showed no skin lesions and demonstrated complete regrowth of the hair on his scalp, beard, and eyebrows. The presence of liver dysfunction with cholestasis in a transplant recipient should alert transplant providers to the possibility of syphilitic hepatitis, particularly in men who have sex with men. Though not an early manifestation, cutaneous signs of secondary syphilis may be a helpful diagnostic indicator in most cases.
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Affiliation(s)
- Carla Ferrándiz-Pulido
- Department of Dermatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Ferrer
- Pathology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Maria Teresa Salcedo
- Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Pathology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marta Velasco
- Department of Dermatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Oscar Len
- Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Lluis Castells
- Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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33
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Fuster C, Belmonte E, Darnell A, Diaz A. Multiple liver masses in a young patient with constitutional syndrome. Liver Int 2020; 40:473-474. [PMID: 31770480 DOI: 10.1111/liv.14312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Carla Fuster
- BCLC Group, Pathology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ernest Belmonte
- BCLC Group, Radiology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Darnell
- BCLC Group, Radiology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alba Diaz
- BCLC Group, Pathology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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Marcos P, Eliseu L, Henrique M, Vasconcelos H. Syphilitic hepatitis: Case report of an overlooked condition. Clin Case Rep 2020; 8:123-126. [PMID: 31998501 PMCID: PMC6982489 DOI: 10.1002/ccr3.2588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 11/11/2022] Open
Abstract
Syphilis is an overlooked cause of hepatitis. Syphilitic hepatitis should be a differential diagnosis in all patients with abnormal liver biochemical marker levels. Syphilitic hepatitis has been defined as the combination of increased liver enzymes, positive serology for syphilis, the absence of alternative causes for hepatobiliary injury, and liver enzyme improvement with proper antibiotic therapy.
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Affiliation(s)
- Pedro Marcos
- Gastroenterology DepartmentCentro Hospitalar de LeiriaLeiriaPortugal
| | - Liliana Eliseu
- Gastroenterology DepartmentCentro Hospitalar de LeiriaLeiriaPortugal
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Abstract
Background Syphilis is a common disease that has been researched and focused on for many years, however, syphilitic hepatitis has not been well-recognized. We report this case of syphilitic hepatitis with intrahepatic cholestasis and liver granulomas to make a deeper impression. Case presentation A 47-year-old male was admitted with jaundice and rashes. The laboratory examination showed abnormal liver enzymes with significant increases in ALP and GGT but mild increases in ALT and AST. His HBV surface antigen was weakly positive, with negative HIV antibody, HCV antibody, and undetectable HBV DNA. The rapid plasma reagin test and the Treponema pallidum particle assay tests for Syphilis were both positive. Abdominal ultrasonography and magnetic resonance cholangiopancreatography revealed the normal biliary tract, liver, and spleen. The liver pathological examination showed cholangiocyte inflammation and micro-granulomas with coagulation necrosis. After 2 months of benzathine penicillin treatment, his liver enzyme decreased rapidly and remained normal after 1-year of follow-up. Conclusions Increased liver enzymes, intrahepatic cholestasis and liver granulomas with well-response to antibiotics may provide clues for the diagnosis of syphilitic hepatitis.
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36
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Bronstein FN, Meyer B, Condat B, Loria A, Bronstein JA. Secondary syphilitic hepatitis in a fifteen-year-old boy. Med Mal Infect 2019; 49:625-627. [PMID: 31611136 DOI: 10.1016/j.medmal.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/31/2019] [Accepted: 07/03/2019] [Indexed: 01/20/2023]
Affiliation(s)
- F-N Bronstein
- Service de gastro-entérologie, centre hospitalier de la Polynésie française, BP 1640, Papeete, Tahiti.
| | - B Meyer
- Service de gastro-entérologie, centre hospitalier de la Polynésie française, BP 1640, Papeete, Tahiti
| | - B Condat
- Service de gastro-entérologie, centre hospitalier de la Polynésie française, BP 1640, Papeete, Tahiti
| | - A Loria
- Service de gastro-entérologie, centre hospitalier de la Polynésie française, BP 1640, Papeete, Tahiti
| | - J-A Bronstein
- Service de gastro-entérologie, clinique Cardella, BP 295, Papeete, Tahiti; Université de Bretagne occidentale, 3, rue des Archives, 29238 Brest, France
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Pizzarossa AC, Rebella M. Hepatitis in patients with syphilis: an overlooked association. BMJ Case Rep 2019; 12:bcr-2018-226918. [PMID: 30696640 PMCID: PMC6350734 DOI: 10.1136/bcr-2018-226918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 01/01/2023] Open
Abstract
We present the case of a patient who sought treatment for fever and a maculopapular rash involving the trunk, limbs, palms and soles. The patient also presented with hepatomegaly and elevated levels of liver enzymes (with a higher increase of alkaline phosphatase). With the proposal of early syphilitic hepatitis, during the stage of secondary syphilis, a venereal disease research laboratory and Treponema pallidum haemagglutination tests were requested, which confirmed the diagnosis. All altered parameters improved with antibiotic treatment for secondary syphilis. Syphilitic hepatitis is an often overlooked presentation of syphilis and should be considered as a differential diagnosis in patients with elevated levels of liver enzymes and risk factors for syphilis.
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Affiliation(s)
| | - Martín Rebella
- Clínica Médica C, Hospital de Clínicas, Montevideo, Uruguay
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