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

Abstract

A 67-year-old male was admitted for progressive liver enzyme elevation. His symptoms began three months prior to this admission, when he presented to the ED with fatigue, decreased appetite, and abdominal pain, and was found to have elevated transaminases. Initial workup by his outpatient gastroenterologist was inconclusive. Subsequently, he developed weakness and numbness that began distal to his axillae and progressed to his torso and lower extremities. On presentation, he attested to anorexia, 18lb weight loss, weakness. He also identified a non-itchy painless rash that began ten days prior on his arms and then spread to his torso, palms and thighs. He denied use of alcohol, tobacco or drugs. He admitted to being sexually active with 5-10 male partners in the past year. No recent travel or sick contacts. No use of antibiotics or herbal supplements. On physical examination, he had scleral icterus, bilateral pitting lower extremity edema. His skin had a non-tender maculopapular rash, most notable on the palms, thighs, chest, and scalp. Admitting labs were significant for total bilirubin 5.9, AST 201, ALT 116, alkaline phosphatase 1048. Abdominal CT scan showed hepatomegaly with heterogeneous attenuation, patent hepatic vasculature, no focal lesions, and mild splenomegaly. MRCP showed no extrahepatic biliary obstruction. Liver biopsy was performed. The coexistence of dermatologic, neurologic and hepatic signs and symptoms prompted evaluation for syphilis. The patient had a reactive RPR titer of 1:256, reactive TPPA and syphilis total antibody ratio of 15.8. Additionally, HIV screening was positive with a viral load of 650,493 copies/mL and CD4+ count of 946 cells/mm3. Liver pathology showed macrovesicular and microvesicular steatosis with focal hepatocellular ballooning and Mallory-Denk bodies, patchy PAS-D positive cytoplasmic hyaline globules, and periportal and sinusoidal fibrosis (image 1). Diagnosis of syphilitic hepatitis was confirmed by immunostain showing numerous treponemal spirochetes (Image 2). He was started on Penicillin G, and his liver enzymes improved impressively (Table 2). A lumbar puncture was performed and showed cell count of 7, non-reactive CSF titer, protein of 55mg/dL, and glucose of 85 mg/dL, thus ruling out neurosyphilis. Thus, it is important that early identification of this infrequent presentation of syphilis is made because of its easy reversibility and subsequent prevention of progression to further stages.2230_A Figure 1 No Caption available.2230_B Figure 2 No Caption available.