Syphilitic hepatitis: an uncommon manifestation of a common disease

"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.

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.

Exploring the Ways of “The Great Imitator”: A Case Report of Syphilitic Hepatitis

Introduction

Syphilis is a chronic infection caused by Treponema pallidum. Manifestations of this disease are vast, and syphilitic hepatitis is a rarely depicted form of secondary syphilis.

Case Presentation

We report the case of a 63-year-old man with worsening jaundice, maculopapular rash and perianal discomfort. Proctological examination with anoscopy revealed a perianal gray/white area with millimetric pale granules along the anal canal. Liver function tests showed a mixed pattern. Venereal Disease Research Laboratory, T. pallidum hemagglutination assay and IgM fluorescent treponemal antibody absorbance were positive. The patient was successfully treated with a single dose of penicillin G.

Discussion/Conclusion

Syphilitic hepatitis is scarcely reported in the literature. Secondary syphilis with mild hepatitis rarely leads to hepatic cytolysis and jaundice. Many signs of secondary syphilis including syphilitic hepatitis may be linked to immune responses initiated during early infection. Over the past decades, evidence has emerged on the importance of innate and adaptive cellular immune responses in the immunopathogenesis of syphilis. This report raises awareness to a clinical entity that should be considered in patients at risk for sexually transmitted diseases, who present with intestinal discomfort or liver dysfunction, as it is a treatable and fully reversible condition.

Atypical case of syphilitic hepatitis

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.

Syphilitic hepatitis; a rare manifestation of a common disease

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.

Spirochetes in the Liver: An Unusual Presentation of a Common STI

It is estimated that 10% of patients with secondary syphilis have liver enzyme elevations, but clinical hepatitis is rare. However, in HIV-positive patients, syphilitic hepatitis may be much more common. We report a case of a 67-year-old male who developed progressively elevated liver enzymes, followed by development of neurological symptoms and then rash. Though the timeline of his symptom development was unusual, his constellation of symptoms prompted an RPR and FTA-ABS which returned reactive. He was additionally found to be HIV positive with a CD4 count of 946. He was treated with IV Penicillin, and his hepatitis improved thereafter.

Liver Cholestasis Secondary to Syphilis in an Immunocompetent Patient

Liver involvement is a known feature of secondary syphilis. The prevalence of hepatitis in secondary syphilis ranges broadly from 1 to 50%. We report a case of a 37-year-old man with type 1 diabetes mellitus and sickle cell trait presenting with jaundice and acute liver cholestasis. Abdominal ultrasound revealed mild hepatic fatty infiltration. RPR and Treponema pallidum IgG results were positive with a reflex titer of 1:64. Liver biopsy revealed chronic hepatitis with normal hepatic architecture, Kupffer cell hyperplasia, hepatic cholestasis, and ductal proliferation suggestive of syphilitic hepatitis.

A Systematic Literature Review of Syphilitic Hepatitis in Adults

Syphilitic hepatitis in adults is not frequently found in the population and is easily misdiagnosed. The incidence of viral hepatitis is increasing year by year, concomitantly increasing the importance of obtaining a systematic understanding of the clinical features and treatment strategies for this disease. There is, however, a lack of published definitive data regarding the clinical characteristics, diagnosis and standard treatment options for this disease. Searches were made using the MEDLINE database of PubMed and OVID for syphilitic hepatitis publications from 1951 to 2017 in an attempt to analyze and summarize the clinical characteristics.

Usefulness of Positron Emission Tomography in Patients with Syphilis: A Systematic Review of Observational Studies

Background:

Diagnosis of syphilis is difficult. Follow-up and therapy evaluation of syphilitic patients are poor. Little is known about positron emission tomography (PET) in syphilis. This review was to systematically review usefulness of PET for diagnosis, disease extent evaluation, follow-up, and treatment response assessment in patients with syphilis.

Methods:

We searched PubMed, EMBASE, SCOPUS, Cochrane Library, Web of Science, ClinicalTrials.gov, and three Chinese databases (SinoMed, Wanfang, and CNKI) for English and Chinese language articles from inception to September 2016. We also collected potentially relevant studies and reviews using a manual search. The search keywords included the combined text and MeSH terms “syphilis” and “positron emission tomography”. We included studies that reporting syphilis with a PET scan before and/or after antibiotic treatment. The diagnosis of syphilis was based on serological criteria or dark field microscopy. Outcomes include pre- and post-treatment PET scan, pre- and post-treatment computed tomography, and pre- and post-treatment magnetic resonance imaging. We excluded the articles not published in English or Chinese or not involving humans.

Results:

Of 258 identified articles, 34 observational studies were included. Thirty-three studies were single-patient case reports and one study was a small case series. All patients were adults. The mean age of patients was 48.3 ± 12.1 years. In primary syphilis, increased fluorodeoxyglucose (FDG) accumulation could be seen at the site of inoculation or in the regional lymph nodes. In secondary syphilis with lung, bone, gastrointestinal involvement, or generalized lymphadenopathy, increased FDG uptake was the most commonly detected changes. In tertiary syphilis, increased glucose metabolic activity, hypometabolic lesions, or normal glucose uptake might be seen on PET. There were five types of PET scans in neurosyphilis. A repeated PET scan after treatment revealed apparent or complete resolution of the asymmetry of radiotracer uptake.

Conclusion:

PET is helpful in targeting diagnostic interventions, characterizing disease extent, assessing nodal involvement, and treatment efficacy for syphilis.

Syphilitic jaundice: a rare manifestation of the secondary stage presenting a missed opportunity to prevent ocular syphilis

The classical presentation of secondary syphilis comprises skin rashes, mucosal ulceration and lymphadenopathy. However, this disseminated stage can also present with symptoms and signs of ocular, neurological, pulmonary, renal, musculoskeletal and digestive tract disease. We report the case of a gay man who presented with icteric hepatitis. Although he underwent an exhaustive series of investigations (some of which were invasive), syphilis was not initially considered in the differential diagnosis. His jaundice resolved spontaneously, but he subsequently developed an acute optic neuritis. Early syphilis is relatively common in men who have sex with men (MSM). Prompt diagnosis and treatment in this case would have prevented ocular involvement. Syphilis testing should be considered in all MSM presenting with unexplained symptoms and signs.