Syphilitic hepatitis

Abstract

A 40-year-old woman with no relevant medical history presented with jaundice with an aspartate aminotransferase (AST) concentration of 172 U/L, an alanine aminotransferase (ALT) concentration of 230 U/L, a total bilirubin concentration of 6·0 mg/dL, a direct bilirubin concentration of 3·6 mg/dL, and an alkaline phosphatase (ALP) concentration of 412 U/L. Full viral hepatitis serological tests and anti-smooth muscle antibodies were negative but anti-nuclear antibodies were positive at 1:640 with a normal IgG concentration. Magnetic resonance cholangiopancreatography showed a normal appearing liver with four prominent retroperitoneal lymph nodes. Laboratory tests on follow-up 6 weeks later showed an AST concentration of 144 U/L, an ALT concentration of 222 U/L, a total bilirubin concentration of 15·0 mg/dL, a direct bilirubin concentration of 9·1 mg/dL, and an ALP concentration of 866 U/L with a positive antimitochondrial antibody (AMA) at 1:320. Percutaneous liver biopsy showed organising microabscesses, mild mixed portal inflammation with bile duct damage, endotheliitis of portal veins, and mild lobular mixed inflammation (figure A, B). After biopsy, she developed a hyperpigmented papulosquamous rash affecting bilateral palms and forearms (figure C). Serum rapid plasma reagin titre was 1:32768 with a positive serum test for syphilis IgG and a negative HIV serological test. She was treated with a 2-week course of continuous intravenous benzylpenicillin 24 million units per day, with resolution of liver chemistries 1 month later. Although Warthin-Starry stain of her liver biopsy was negative for spirochaetes, the Centers for Diseases Control and Prevention reported positive Treponema spp immunohistochemistry confirming syphilitic hepatitis.