Syphilitic Hepatitis, a Rare Presentation of the Great Imitator

Abstract

Well-known as the “great imitator”, syphilis is a sexually transmitted disease caused by Treponema pallidum with many manifestations and is one of the rarer recognized etiologies of liver failure. Syphilitic hepatitis presents with cholestatic transaminitis, skin manifestations of secondary syphilis, and rarely fulminant liver failure. Work-up should exclude other etiologies of liver disease. Testing for co-infection of other sexually transmitted diseases including HIV should be performed. Early recognition of symptoms can lead to excellent outcomes with treatment in this antibiotic era of medicine. We present a case of a 49-year-old male with a history of hypertension who complained of malaise and a new diffuse, progressive, non-pruritic body rash for three weeks. He complained of headaches and jaundice for the last four days. He was previously in the military and lived in South Korea, Arab Emirates and Germany but without recent travel, new medications, or exposure to sick contacts. He was in a monogamous relationship with a female partner but recently found out that she had other sexual partners. He occasionally drank alcohol but denied use of tobacco or illicit drugs. On examination he was in no distress, afebrile and with normal vital signs. He had scleral icterus and jaundice. There was a symmetric maculopapular rash involving the trunk, extremities, palms and soles. There were no penile lesions or lymphadenopathy. Laboratory studies included elevated transaminases with aspartate aminotransferase (AST) 88 U/L, alanine aminotransferase (ALT) 223 U/L, alkaline phosphatase of 545 U/L and total bilirubin 15.2 mg/dL with conjugated bilirubin 10.8 mg/dL. HIV screening was negative. Rapid plasma reagin (RPR) and treponemal antibody were positive (titer 1:256). Magnetic resonance cholangiopancreatography (MRCP) showed a complex hepatic cyst and pancreatic cysts but no signs of obstruction or cirrhosis. CSF analysis revealed a positive venereal disease research laboratory (VDRL). The patient was diagnosed with syphilitic hepatitis, secondary syphilis and neurosyphilis. He was treated with three doses of weekly intramuscular benzathine and fourteen days of intravenous penicillin G. Symptoms resolved with completion of treatment. This case underlines the importance of maintaining clinical awareness of rare presentations such as syphilitic hepatitis as incidence of syphilis continues to rise in the United States.Figure: Diffuse maculopapular rash in palms, trunk, extremities and soles bilaterally.Figure: Timeline of total bilirubin changes after initiation of treatment.Figure: Timeline of alkaline phosphatase changes after initiation of treatment.