S3020 Hepatitis From a Sexually Transmitted Bacterial Infection

Abstract

Introduction: Syphilis is a multisystemic, sexually transmitted infection (STI) that is caused by the spirochete Treponema pallidum. Hepatic involvement is rare. We present a patient who was diagnosed with syphilitic hepatitis (SH). Case Description/Methods: A 54-year-old male presented to the hospital with one week of sharp upper abdominal pain, jaundice, poor appetite, and a 25-lb. weight loss. He also reported multiple sexual partners and a rash that developed 2 months ago. Vital signs were within normal range. Physical examination revealed scleral icterus, a soft, non-tender abdomen, a plaque-like penile lesion and small, circular lesions on his palms and soles of feet. Laboratory studies revealed aspartate aminotransferase (AST) 164 U/L, alanine aminotransferase (ALT) 207 U/L, alkaline phosphatase (ALP) 1395 U/L, total bilirubin 5.6 mg/dL, gamma-glutamyl transferase 782 U/L. Hepatitis panel, acetaminophen and alcohol levels were negative. Chronic liver disease work-up was unremarkable. Treponemal antibody and rapid plasma reagin test were both positive. HIV test and cerebrospinal fluid venereal disease research laboratory (VDRL) test were negative. Abdominal ultrasound and CT scan of the abdomen were unremarkable. Magnetic resonance cholangiopancreatography was notable for hepatomegaly and hepatitis. Patient received 1 dose of penicillin G 2.4 million units intramuscularly with remarkable improvement in his symptoms and liver function tests. He was discharged home with close follow-up with gastroenterology and infectious disease. Discussion: SH occurs in 0.2-9.7% of patients with syphilis and is most commonly seen in the primary and secondary disease stages. Clinical manifestations include a maculopapular rash (involving the trunk, palms and/or soles of feet), fatigue, poor appetite, hepatomegaly and icterus. Liver function tests (LFTs) may reveal a marked increase in ALP and GGT in comparison to ALT and AST. SH is diagnosed with abnormal LFTs, serological evidence of syphilis, exclusion of other liver diseases and LFTs returning to normal after antibiotic therapy as in our patient. The histological features of SH include inflammatory infiltration of the bile duct and hepatic granulomas. Spirochetes are often difficult to identify in liver tissue. Penicillin is the mainstay of treatment. Clinicians should consider syphilitic hepatitis in a patient with abnormal LFTs (especially ALP) and a rash involving the palms and soles of feet in the appropriate clinical context.