Bilateral Palms Research Articles

MANAGEMENT OF HAND ECZEMA (VICHARCHIKA) THROUGH AYURVEDA: A CASE STUDY

Eczema is referred to as "atopic dermatitis." It's a chronic inflammatory skin condition characterised by itchy, red, and dry skin and sometimes scaly patches of skin. These patches may become thickened, cracked, or scaly and can occur anywhere on the body. Eczema often involves periods of flare-ups and remissions and can vary from mild to severe. It is considered a type of allergic or atopic condition, and it's commonly associated with other allergic conditions such as asthma and hay fever. Eczema resembles Vicharchika in Ayurveda. The signs and symptoms of Vicharchika are kandu (itching), pidika (papule), shyava varna (blackish-brown discolouration), and bahusrava (excessive exudation). Case summary: A 29-year-old female patient approached Kayachikitsa Skin OPD with complaints of dry, scaly skin lesions over bilateral palms with redness, cracking, and occasional discharge from lesions associated with severe itching for 10 years; symptoms have aggravated for 15 days. Based on signs and symptoms, an Ayurvedic diagnosis was made as Vicharchika (hand eczema). The subject was given deepana (appetiser)-pachana (carminative), bahya rukshana karma (external dehydrating therapy), then snehapana (internal oleation), followed by Virechana (purgation therapy), and shamana aushadhis (oral medications). The subject showed improvement in signs and symptoms, EASI and DLQI scores.

Palmoplantar Erythrodysesthesia: An Unusual Side Effect of Lenvatinib

Palmoplantar erythrodysesthesia also known as hand-foot syndrome is an intense, painful erythema of the palms and soles due to chemotherapeutic drugs. The most commonly implicated drugs are multi-kinase inhibitors such as sorafenib, sunitinib, doxorubicin, cytarabine, and docetaxel. The most effective management is withdrawal or reduction of drugs. Oral and topical corticosteroids and dimethyl sulfoxide are other treatment options. A 67-year-old male patient of hepatocellular carcinoma taking tablet lenvatinib presented with multiple tender erythematous plaques and patches over the bilateral palms and dorsum of the fingers after 1 month of initiation of therapy. The patient was successfully treated with dose reduction of lenvatinib and topical corticosteroids and is maintained on medium potency corticosteroid.

AN AYURVEDIC MANAGEMENT OF PALMO-PLANTAR PSORIASIS BY BAKULA PATRA- A CASE STUDY

Background Skin diseases are a group of diseases that a larger population of the world is suffering from. Care for the skin is emphasised, as it is the largest organ of our body. In Ayurveda, all skin diseases are dealt with under Kushta. Vipadika Kusthta is one of the Kshudrakusta, which occurs due to Tridosha Prakopa. This causes Teevra Ve-dana, Pani Pada Sputana. In the modern system of medicine, Vipadika Kusta can be correlated to Palmo-plantar psoriasis. The national prevalence of Palmoplantar psoriasis is estimated to be 0.12%. The symptoms include elevated and thickened skin surface, scaling, itching, burning sensation, cracks and bleeding. Aim- To evaluate Bakula Patra Kashaya's efficacy in managing Palmoplantar psoriasis. Methodology- In the present case, a fe-male patient aged 74 years complained of itching, burning sensation, cracks, and scaling over bilateral soles and palms for three months. It was initially treated with Bakula Patra Kashaya for fifteen days, and Shodhana was given, which included Snehapana with Panchatiktaka Guggulu Grita for three days, Vishramakala where Sar-vanga Abhyanga with Yastimadhu Taila for three days in the absence of Swedana and on 7th day Virechana with 25gm Trivrut Lehya followed by 60ml Draksha Rasa was given. Results—Vipadika Kusta was assessed using subjective and objective criteria based on Lakshanas, and the score was noted before and after the treatment. The symptoms were significantly improved after the consumption of Bakula Patra Kashaya. Conclusion- Mimosops elengi Linn, belonging to the Sapotaceae family, is indicated in Twak Vikaras. The leaves contain active princi-ples like Quercetin, Hentriacontane, and steroidal saponin, which have wound-healing properties and might have helped heal cracks. Quercetin has anti-histaminic activity, which might have reduced itching.

Management of Vaipadika (Palmo Plantar Psoriasis) through Shodhana and Shamana- A Case Study

A localized form of Psoriasis known as Palmo plantar psoriasis is characterized by the development of thick, scaly and hyperkeratotic plaques. Despite the fact that this disease mostly affects the palms and soles, the hardness of the skin makes it difficult to do daily tasks. This condition is related to Vaipadika in Ayurveda. In the framework of Kshudra kusta, Vaipidika is explained. This illness is mostly caused by the Vatakapha dosha, which is identified by Pani pada sphuthana and Teerva vedhana. Here is a case of a 55 years old female with history of dryness ,scaling and cracks over her bilateral palms and soles associated with pain , blackish discoloration and severe itching and burning sensation, associated with bloody discharge since 1 year .Patient was treated with Snehana and Swedana and later Shamana oushadi were given for 7 days along with life style modification. Patient had good relief in symptoms.

Palmoplantar keratoderma climactericum successfully treated with topical oestrogen

AbstractKeratoderma climactericum is characterized by palmoplantar hyperkeratosis developing after the onset of menopause. Although rare, keratoderma climactericum can profoundly impact quality of life and may be refractory to prescription‐strength topical steroids and keratolytics. We report a 52‐year‐old female with a 1‐year history of palmoplantar keratoderma. She had a medical history of generalized anxiety disorder and had reached menopause 2 years before presentation. Previously failed treatments included clotrimazole 1% cream twice daily, triamcinolone 0.1% cream twice daily, and betamethasone 0.05% cream mixed with tazarotene 0.1% cream twice daily. She was diagnosed with keratoderma climactericum, and conjugated oestrogen 0.625 mg/g cream twice daily was initiated. After 4 weeks, she had dramatically reduced erythema and hyperkeratosis of her bilateral palms and soles. No adverse effects to treatment were reported. Although the utility of topical oestrogen for keratoderma climactericum has been debated, our case provides further evidence for its efficacy and safety.

Multiple yellowish pinpoint papules on bilateral palms

JDDG: Journal der Deutschen Dermatologischen GesellschaftEarly View CASE FOR DIAGNOSIS Multiple yellowish pinpoint papules on bilateral palms Shou-En Wu, Shou-En Wu Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorWei‑Ming Wang, Wei‑Ming Wang Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorChien‑Ping Chiang, Chien‑Ping Chiang Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Biochemistry, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorChih-Tsung Hung, Chih-Tsung Hung Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorYi-Hsien Chen, Corresponding Author Yi-Hsien Chen [email protected] Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Correspondence Yi‑Hsien Chen, MD, Department of Dermatology, Tri‑Service General Hospital, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. Taipei City 114, Taiwan. Email: [email protected]Search for more papers by this author Shou-En Wu, Shou-En Wu Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorWei‑Ming Wang, Wei‑Ming Wang Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorChien‑Ping Chiang, Chien‑Ping Chiang Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Biochemistry, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorChih-Tsung Hung, Chih-Tsung Hung Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TaiwanSearch for more papers by this authorYi-Hsien Chen, Corresponding Author Yi-Hsien Chen [email protected] Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Correspondence Yi‑Hsien Chen, MD, Department of Dermatology, Tri‑Service General Hospital, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. Taipei City 114, Taiwan. Email: [email protected]Search for more papers by this author First published: 27 March 2023 https://doi.org/10.1111/ddg.15011AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

“Wood-Bark Sign” in Dermoscopy of Aquagenic Syringeal Acrokeratoderma

“Wood-Bark Sign” in Dermoscopy of Aquagenic Syringeal Acrokeratoderma

A Preliminary Study on Infrared Thermograph of Metabolic Syndrome.

ObjectiveTo explore the temperature distribution characteristics of the face, palms, feet and the trunk area of metabolic syndrome (MS) through infrared thermography (IRT) and provide evidence for the application of IRT in the assistant evaluation of MS population.MethodsWe collected thermographs of 184 participants (91 males, 93 females) and further divided participants of each gender into 4 groups according to the number of abnormal metabolic indexes. Mean temperatures of 6 Region of Interests (ROIs) (face, anterior trunk, bilateral palms and dorsum of feet) were calculated. Comparisons of the mean temperatures between genders, among groups and ROIs were carried out.ResultsMale participants had higher mean temperature in their face, palms (P<0.01) and dorsum of feet (P<0.05), and lower mean temperature in the anterior trunk (P<0.01). Female participants with MS had higher mean temperature in their palms and dorsum of feet (P<0.01) and lower mean temperature in the anterior trunk (P<0.01) than normal participants. Similar tendencies were shown in the mean temperature of the left palms and trunk of MS males. With the increase of the number of abnormal metabolic indexes, it seems that the mean temperature gradually increased in palms and dorsum of feet, and decreased in the anterior trunk.ConclusionThe thermograph of MS exhibits certain characteristics. This may help reveal the correlations between Infrared thermography and metabolic disorders.

A Female with Mucocutaneous Telangiectases and Portal Hypertension

Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia, is a rare autosomal dominant disorder manifested by telangiectases of the skin and mucous membranes and arteriovenous malformations of various organ systems. We report a case of 45-year-old postmenopausal woman who presented to dermatology department for evaluation of compressible vascular lesion involving bilateral palms and oral cavity for the past 3 months' duration. On further evaluation, she was found to have portal hypertension and multiple cavernoma formation on place of portal vein.

Management of Pediatric Pavement Burns.

Pavement burns are common in a dry high heat climate. This study reviews the etiology, management, and outcome pavement burns in children. All patients age <18 who sustained contact burns from hot pavement from January 1, 2014 to December 31, 2019 were reviewed for mechanism, medical history, treatment course, and outcome. The high ambient temperature on each date and zip code of each injury were extracted from Weather Underground (www.wunderground.com). In this study, 45 patients met criteria and were reviewed 27 patients (60%) were male. Average age was 3.29 years (SD 0.69), made up two discrete age groups: age 3 years and under (n = 40, 89%) and older patients 14 years of age and up (n = 5, 11%). Thirty-eight patients (84%) had no known medical history. All had second-degree burns and one patient (2%) also had third-degree burns. Mean TBSA was 2.5% (SD 1.4%, range 0.75%-5.5%). Burn etiology included 31 patients (69%) who were walking barefoot on pavement, six (13%) who fell onto pavement, one (2%) seizure, and other/unknown etiology for the remaining seven patients (16%). Thirty patients (67%) had injuries on the plantar aspect of the bilateral feet, two (4%) to bilateral palms of hands, four (9%) to other parts of upper extremities, and 10 (22%) to other parts of lower extremities. Thirty-four patients (76%) were managed without any hospitalization. Those that were hospitalized had an average length of stay of 2.72 days (range 1-9 days). All burns were managed nonoperatively with topical therapy alone. Thirty-four patients (76%) were managed initially with silver sulfadiazene alone and six (13%) with bacitracin alone. Aquacel dressing was utilized in 10 patients at a follow-up visit (22%). Three patients (6.7%) were treated with collagenase enzyme therapy at some point in their care. One patient developed a superficial infection requiring oral antibiotic therapy. There were no mortalities in this group. High ambient temperature on date and location of each injury was 102.1°F (SD 5.4°F, range 89-111°F). Of the 30 patients that continued to follow up in clinic the average time to the burn being 95% healed was 10.50 days (SD 8.97 days, range 2-40 days). Pavement burns in children are partial thickness and are safely managed with topical therapy alone with good outcomes. Patients age 3 and under are at high risk.

546 Management of Pediatric Pavement Burns

Abstract Introduction Pavement burns are common in a dry high heat climate. This study reviews the etiology, management and outcome of pavement burns in children. Methods All patients age &amp;lt; 18 who suffered contact burns from hot pavement from Jan 1, 2014 to Dec 31, 2019 were reviewed. A total of 45 patient charts met inclusion criteria. High ambient temperature on each date, and zip code of each injury was extracted from Weather Underground (www.wunderground.com) Results In this study, 45 patients met criteria and were reviewed, of whom 27 patients (60%) were male. Average age was 3.29 years (SD 0.69), made up two discrete age groups: age under 3 (n= 40, 89%) and 14+ (n=5, 11%). 38 patients (84%) had no known medical history. All had 2nd degree burns and one patient (2%) had third degree burns. Mean total body surface area (TBSA) was 2.5% (SD 1.4%, range 0.75% to 5.5%). Burn etiology included 31 patients (69%) walking barefoot on pavement, 6 (13%) falling onto pavement, and other/unknown etiology for the remaining 8 patients (18%). 30 patients (67%) had injuries on the plantar aspect of bilateral feet, 2 (4%) to bilateral palms of hands, 4 (9%) to other parts of upper extremities and 10 (22%) to other parts of lower extremities. Thirty-four (34) patients (76%) were managed without any hospitalization. Those that were hospitalized had an average length of stay (LOS) of 2.72 days (range 1–9 days). All burns were managed non-operatively with topical therapy alone. 35 patients (78%) were managed initially with Silvadene, and 6 (13%) with bacitracin. Aquacel was utilized in 10 patients at a follow-up visit (22%). Three patients (6.7%) were treated with collagenase enzyme therapy. One patient developed a superficial infection requiring oral antibiotic therapy. There were no mortalities in this group. The high ambient temperature on date and location of each injury was 101 F (SD 1.10 F, range 73F-111F). Of the thirty that continued to follow up in clinic, the average time to the burn being 95% healed was 10.50 days (SD 8.97 days, range 2–40 days). Conclusions Pavement burns in children are partial thickness and are safely managed with topical therapy alone, with good outcomes. Patients age 3 and under are a vulnerable population and therefore at particular risk of injury.

Palmar petechiae in a patient with diabetes mellitus

A 64-year-old man with a history of celiac disease (CD), congestive heart failure, and diabetes mellitus complicated by end-stage renal disease and peripheral neuropathy, was admitted to the hospital for non-healing ulcerations of his hands with osteomyelitis from his peripheral arterial vascular disease. He reported that his CD was under good control with a strict gluten-free diet prior to admission. Physical exam revealed prominent petechiae on his bilateral palms and fingers (Fig 1). A biopsy was performed and demonstrated collections of neutrophils in the papillary dermis (Fig 2).

A case of spiny keratoderma associated with chronic kidney disease

Dear Editor, A 72‐year‐old woman presented with a 3‐year history of numerous asymptomatic pinpoint keratotic lesions localised to bilateral palms with infrequent lesions to bilateral plantar feet. The patient reported no other dermatological history and family history of similar lesions and denied prior arsenic exposure. Her past medical history was significant for type 2 diabetes mellitus, chronic kidney disease stage 3B secondary to diabetic nephropathy, hypertension, dyslipidaemia and hypothyroidism.

Phenytoin Induced Erythema Multiforme

<p style="text-align: justify;">Phenytoin is conventional antiepileptic drug is effective in the treatment of generalized tonic-clonic seizures but its adverse effects makes its usage limited. We herein present the case of Phenytoin induced Erythema Multiforme. A 65-year-old elderly female presented to our hospital with a 3 days history of itching all over the body, multiple reddish lesions over bilateral arms, forearms, anterior aspect of chest, trunk, bilateral palms and soles. Patient developed skin lesion 1 month after and she started taking phenytoin 100 mg twice a day for left frontal temporal subdural hematoma. Dermatological examination revealed multiple tangloid lesions over the lateral aspect of neck. Phenytoin was discontinued and the skin lesions resolved spontaneously within 2 weeks. The health-care professionals should be aware of such dermatological reactions so that it can be diagnosed and treated early. <p style="text-align: justify;"><strong>Key words: </strong> Antiepileptic, Erythema multiforme, Phenytoin.

Palmoplantar hyperkeratotic projections

Palmoplantar hyperkeratotic projections

2103 Resolution of Infliximab-Induced Palmar Pustular Psoriasis (PPP) After Switching to Biosimilar Infliximab-DYYB

INTRODUCTION: Biosimilars are designed to approximate the effectiveness and safety profile of the reference drugs they are based upon. A person who has a side effect to either the biosimilar or the reference drug would have a similar adverse event to the other medication. Infliximab is an anti-TNF drug used in a variety of autoimmune conditions including UC. While highly effective, it is associated with new onset psoriasis in 5-9% of patients with IBD. That is not typically an indication to abandon the medication if it is otherwise effective. We describe the case of a person with UC on infliximab with the adverse event of PPP who was changed to infliximab-dyyb for financial reasons and had resolution of their skin lesions. CASE DESCRIPTION/METHODS: A 68 year old F with history of pancolonic UC was started on Infliximab 5 mg/kg/8 weeks. After 8 months of therapy and due to unresolved inflammation and symptoms, infliximab was increased to 10 mg/kg/8 weeks resulting in clinical remission. She had no prior history of psoriasis or other skin disease but after one year on infliximab she developed a new rash, examination showed well demarcated, pruritic, tender raised erythematous plaques on bilateral palms with salmon colored papules and small pustules (Figures 1 and 2). Dermatology diagnosed her with PPP secondary to infliximab. She was treated for over a year with clobestasol ointment with only modest improvement. Due to infusion center policy, her infliximab was changed to infliximab-dyyb. On 3 month follow up it was noted that the rash had completely resolved since switching to the biosimilar (Figure 3). DISCUSSION: Biosimilars of biologic therapies have become increasingly available. They are designed to recreate the effectiveness and safety of the reference medication. While some people develop side effects or loss of response when switching to a biosimilar from a reference medication, adverse events tend to happen at the same rate, suggesting that the event is not due to the biosimilar. Psoriasis caused by anti-TNF is a known adverse reaction. This may be due to a disruption in the balance from TNFα leading to increased production of IFN gamma. In studies infliximab led to psoriasis 5-9% compared to 5-12% in infliximab-dyyb. Even though it is believed that both the reference drug and biosimilar drug have similar efficacy and adverse reaction profiles, we hypothesize that our patient may have developed an immunogenic reaction to a part of the infliximab molecule that is not present in its biosimilar product infliximab-dyyb.

Clinical analysis of four cases of dermatomyositis with painful palmar eruptions complicated by fatal rapidly progressive interstitial lung disease

Objective To firstly report 4 cases of dermatomyositis characterized by painful palmar eruptions complicated by fatal rapidly progressive interstitial lung disease (RP-ILD) in China. Methods Four patients with dermatomyositis with painful palmar eruptions complicated by fatal RP-ILD were enrolled from the Department of Dermatology, Zhongshan Hospital, Fudan University between December 2014 and April 2017, and their clinical and pathological features were analyzed. Results Among these patients, 3 were female and 1 was male. Their age ranged from 47 to 59 years. Of the 4 patients, 3 had no muscular involvement. All of the 4 patients had multiple solid red papules or nodules on the bilateral palms, palmar and lateral surfaces of fingers, which preceded, followed or concurred with the onset of other skin lesions of dermatomyositis. The occurrence of type Ⅰ respiratory failure was preceded by 3 weeks to 5 months of painful palmar eruptions in the 4 patients. Early-stage palmar eruptions were easily misdiagnosed as contact dermatitis, eczema or erythema multiforme. Histopathological examination of the skin lesions on the finger palmar surface showed perivascular infiltration of a few lymphocytes in the dermis, and deposition of varying amounts of mucin-like substances around blood vessels and appendages. Of the 4 patients, 3 showed positive staining for anti-melanoma differentiation-associated gene 5 antibody. Although the 4 patients received anti-inflammatory and immunosuppressive therapies, they all finally died of respiratory failure. Conclusions Dermatomyositis with painful palmar eruptions may indicate the occurrence of fatal RP-ILD, and early biopsy of skin lesions is needed to help to identify the disease. Immunosuppressive treatment should be performed timely to improve the prognosis in these patients. Key words: Dermatomyositis; Lung diseases, interstitial; Skin manifestations; Hand; Pain; Glucocorticoids; Immunosuppressive agents

Kikuchi-Fujimoto disease: an unusual presentation of meningitis in a returning traveller

A 19-year-old, previously healthy woman developed a pruritic erythematous maculopapular rash on her bilateral palms and wrists, right-sided tender cervical lymphadenopathy and nightly fevers and headaches 5 days after returning...

Syphilitic hepatitis

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.

Syphilitic Hepatitis

40 year-old woman with a history of Guillain-Barré syndrome, Bell's Palsy, hypertension, and migraines presented with jaundice with aspartate aminotransferase (AST) 172 U/L, alanine aminotransferase (ALT) 230 U/L, total bilirubin 6.0 mg/dL, direct bilirubin 3.6 mg/dL, and alkaline phosphatase 412 U/L. Full viral hepatitis serologies and anti-smooth muscle Ab were negative, anti-nuclear antibodies (ANA) was positive at 1:640 with a normal IgG level. MRI/MRCP demonstrated a normal appearing liver with a few prominent retroperitoneal lymph nodes. Labs on follow-up six weeks later demonstrated AST 144 U/L, ALT 222 U/L, total bilirubin 15.0, direct bilirubin 9.1, alkaline phosphatase 866 U/L with a positive Antimitochondrial Antibody (AMA) at 1:320. Percutaneous liver biopsy demonstrated organizing microabscesses, mild mixed portal inflammation with bile duct damage, endotheliitis of portal veins, and mild lobular mixed inflammation. After biopsy, she developed a hyperpigmented papulosquamous rash affecting bilateral palms and forearms. Serum rapid plasma regain (RPR) was 1:32768 with positive serum syphilis IgG Ab and negative HIV testing. She was treated with a two-week course of continuous IV Penicillin G 24 million units daily, with resolution of liver chemistries one-month later. While Warthin Starry stain of her liver biopsy at our institution was negative for spirochetes, the Centers for Diseases Control (CDC) reported positive Treponema spp. immunohistochemistry confirming syphilitic hepatitis. Liver abnormalities characterized by a disproportionally elevated alkaline phosphatase and normal or mildly increased bilirubin and aminotransferases are reported in 30-40% of early syphilis cases, and typically rapidly normalize with antibiotic treatment. However, severe cholestasis, jaundice, and one episode of acute liver failure has been reported. As in our patient, AMA positivity has been reported with syphilitic hepatitis. There are nine mitochondrial autoantigens (M1-9), of which M2 is specific for primary biliary cholangitis (PBC). In syphilis, antibodies to cardiolipin (M1) can form which explains the positive result. M1 and M2 can be distinguished by M2-specific ELISA testing. Early syphilis is on the rise in the US, and must remain on the differential for clinicians evaluating acute cholestatic liver injury. Furthermore, clinicians must be aware of the potential false-positive AMA, as the pattern of liver injury could be confused with PBC.Figure: Histologic sections of the liver demonstrate organizing microabscesses, composed of numerous neutrophils, lymphocytes, plasm cells, and histiocytes. H&E stain, original magnification 400x.Figure: Histologic sections of the hepatic portal tracts demonstrate mild mixed inflammation with bile duct damage (larger arrows) and endothelitis of portal veins (smaller arrows). Periportal hepatocytes show intracytoplasmic cholestasis (arrowheads). H&E stain, original magnification 400x.Figure: Hyperpigmented papulosquamous rash affecting the patient's bilateral palms and forearms.