Scientific letter
Acute hepatitis as a manifestation of secondary syphilis
Hepatitis aguda como manifestación de sífilis secundaria
Raúl Honrubia-López
, Jose Luis Rueda-García, Aurora Burgos-García, Ruben Fernández-Martos, Pedro Mora-Sanz
Corresponding author
Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, Spain
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However, other much less common infectious agents can also cause acute hepatitis in the context of systemic diseases. We present the case of a patient diagnosed with secondary syphilis with hepatic involvement.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was a 26-year-old homosexual male with no relevant previous medical history. He went to Accident and Emergency with a two-week history of asthenia, epigastric pain, pharyngeal discomfort and mucocutaneous jaundice. His regular partner had been diagnosed with syphilis two months earlier, so the patient had also had serology for <span class="elsevierStyleItalic">Treponema pallidum</span> at that time, which was negative. He reported no fever, altered bowel habit, recent travel, contact with small children, tattoos or previous transfusions, use of potentially hepatotoxic substances or ingestion of spoiled food.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination, an ulcer was found on the left tonsil with a blackish fibrinous base (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), in addition to jaundice. There were no signs of lymphadenopathy, skin lesions, genital lesions or neurological alterations.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests showed abnormal liver function tests, predominantly with cholestasis [aspartate aminotransferase (AST): 176<span class="elsevierStyleHsp" style=""></span>IU/l; alanine aminotransferase (ALT): 371<span class="elsevierStyleHsp" style=""></span>IU/l; gamma-glutamyl transpeptidase (GGT): 540<span class="elsevierStyleHsp" style=""></span>IU/l; alkaline phosphatase (AP): 1032<span class="elsevierStyleHsp" style=""></span>IU/l; and total bilirubin of 7.9<span class="elsevierStyleHsp" style=""></span>mg/dl] with complete blood count, coagulation and other basic clinical biochemistry normal. Abdominal ultrasound showed no abnormal findings.</p><p id="par0025" class="elsevierStylePara elsevierViewall">One month before attending Accident and Emergency, the patient had been assessed in Hepatology Outpatients for non-specific malaise with slight elevation of transaminases, and a full investigation for liver disease was requested. Serology for common hepatotropic viruses (hepatitis A, B, <span class="elsevierStyleSmallCaps">C</span> and E) as well as HIV, autoimmunity (ANA, AMA, anti-LKM and smooth muscle antibodies), iron profile, ceruloplasmin and alpha-1 AT were all negative. Serology for syphilis was repeated, resulting in positive IgG, rapid plasma reagin (RPR) test 1/32 and positive <span class="elsevierStyleItalic">T. pallidum</span> haemagglutination assay (TPHA). A sample was taken of the ulcer on the left tonsil, interpreted as syphilitic chancre, with <span class="elsevierStyleItalic">T. pallidum</span> confirmed in the genome amplification.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As secondary syphilis with hepatic involvement was suspected, treatment was prescribed with penicillin G benzathine. The patient made good progress, with improvement both clinically and analytically.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Syphilis is a sexually or vertically transmitted disease caused by the spirochete <span class="elsevierStyleItalic">T. pallidum</span>. Syphilitic liver involvement is very uncommon (<1% of cases) and can occur in the secondary or tertiary phase of disease<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> due to multiplication and haematogenous spread of the spirochete to the liver.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> In the secondary syphilis phase, cholestasis occurs, with a characteristic elevation of alkaline phosphatase; this is usually accompanied by pyrexia, the typical palmoplantar rash and even nephrotic syndrome, although all three signs do not always have to be present.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> In the tertiary phase, the characteristic lesions are syphilitic gummas, most common in the right lobe of the liver and generally asymptomatic, unless they cause compression leading to Budd–Chiari syndrome.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis can be established in the presence of abnormal liver function tests, positive serology and improvement after antibiotic treatment.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> The liver biopsy findings are not pathognomonic (periportal necrosis, endotheliitis, cholangitis or pericholangitis) unless the spirochete is detected in the hepatic lobule, which is very uncommon.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Therefore, although some authors consider it advisable to perform a liver biopsy for the definitive diagnosis,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> it does not seem to be essential. In most of the patients described in the literature, syphilis coexists with other sexually transmitted diseases (HBV, HCV, HIV, etc.),<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> so it has to be taken into account that finding one cause of liver disease does not exclude others.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The treatment of syphilitic hepatitis consists of administration of penicillin G benzathine, or doxycycline or macrolides in the case of allergy to beta-lactams.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> In the second week of treatment, jaundice (an idiosyncratic reaction known as Jarisch–Herxheimer) with uncertain pathophysiology may develop,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> but it clears up without sequelae in virtually all cases.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In our patient, liver involvement represented an unusual manifestation of secondary syphilis, as no pyrexia, palmoplantar rash or nephrotic syndrome were detected. Nor did he have any other concomitant sexually transmitted disease. The previous epidemiological history in his partner (not revealed initially by the patient), the cholestasis with elevation of alkaline phosphatase and, finally, the positive serology, pointed to the diagnosis. The atypical location of the syphilitic chancre on the tonsil was interesting and confirms the importance of a thorough history and physical examination. As the genome amplification was positive for <span class="elsevierStyleItalic">T. pallidum</span> and the patient had an excellent response to the antibiotic treatment, liver biopsy was not considered necessary.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, liver dysfunction related to secondary syphilis is an uncommon occurrence, but should be suspected in at-risk patients. Liver biopsy is not considered essential for diagnosis in all cases. In the majority of patients, the outcome is excellent once they start treatment with penicillin G benzathine.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Honrubia-López R, Rueda-García JL, Burgos-García A, Fernández-Martos R, Mora-Sanz P. Hepatitis aguda como manifestación de sífilis secundaria. Gastroenterol Hepatol. 2018;41:505–506.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 92147 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulcer on left tonsil with blackish, fibrinous base (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A great masquerader: acute syphilitic hepatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Lee" 1 => "C. Wang" 2 => "R. Dorer" 3 => "L. Ferguson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10620-012-2322-1" "Revista" => array:6 [ "tituloSerie" => "Dig Dis Sci" "fecha" => "2013" "volumen" => "58" "paginaInicial" => "923" "paginaFinal" => "925" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22833383" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Luetic hepatitis. An emerging entity" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Ibáñez" 1 => "M. Varela" 2 => "M. Rodríguez-Peláez" 3 => "A. Mancebo" 4 => "M.A. García-Mayor" 5 => "R. Pereira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gastrohep.2009.05.001" "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Hepatol" "fecha" => "2009" "volumen" => "32" "paginaInicial" => "610" "paginaFinal" => "613" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19625105" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome nefrótico y hepatitis en sífilis temprana" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.L. Tang" 1 => "R.N. Thin" 2 => "D.N. Croft" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Postgrad Med J" "fecha" => "1989" "volumen" => "65" "paginaInicial" => "14" "paginaFinal" => "15" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2780445" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tertiary hepatic syphilis. A treatable cause of multinodular liver" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Maincent" 1 => "H. Labadie" 2 => "M. Fabre" 3 => "P. Novello" 4 => "K. Derghal" 5 => "C. Patriarche" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dig Dis Sci" "fecha" => "1997" "volumen" => "42" "paginaInicial" => "447" "paginaFinal" => "450" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9052534" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Syphilitic hepatitis in HIV-infected patients: a report of 7 cases and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.J. Mullick" 1 => "A.P. Liappis" 2 => "D.A. Benator" 3 => "A.D. Roberts" 4 => "D.M. Parenti" 5 => "G.L. Simon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2004" "volumen" => "39" "paginaInicial" => "100" "paginaFinal" => "105" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A forgotten aetiology of acute hepatitis in immunocompetent patient syphilitic infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Mandache" 1 => "C. Coca" 2 => "F. Caro-Sampara" 3 => "F. Haberstezer" 4 => "D. Coumaros" 5 => "F. Blicklé" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2796.2005.01596.x" "Revista" => array:6 [ "tituloSerie" => "J Intern Med" "fecha" => "2006" "volumen" => "259" "paginaInicial" => "214" "paginaFinal" => "215" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16420551" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatitis y glomerulonefritis en sífilis secundaria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Balikocioglu" 1 => "E. Quaidoo" 2 => "J.C. Vulentin" 3 => "B.W. Trotman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Assoc Acad Minor Phys" "fecha" => "1991" "volumen" => "2" "paginaInicial" => "72" "paginaFinal" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1810584" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0210569117300293" "estado" => "S300" "issn" => "02105691" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Syphilis treatment: old and new" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Dayan" 1 => "C. Ooi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1517/14656566.6.13.2271\t" "Revista" => array:6 [ "tituloSerie" => "Expert Opin Pharmacother" "fecha" => "2005" "volumen" => "6" "paginaInicial" => "2271" "paginaFinal" => "2280" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16218887" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24443824/0000004100000008/v1_201810020619/S244438241830155X/v1_201810020619/en/main.assets" "Apartado" => array:4 [ "identificador" => "48446" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004100000008/v1_201810020619/S244438241830155X/v1_201810020619/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S244438241830155X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 54 | 10 | 64 |
| 2024 September | 63 | 15 | 78 |
| 2024 August | 76 | 19 | 95 |
| 2024 July | 51 | 9 | 60 |
| 2024 June | 84 | 2 | 86 |
| 2024 May | 71 | 4 | 75 |
| 2024 April | 57 | 2 | 59 |
| 2024 March | 83 | 3 | 86 |
| 2024 February | 68 | 5 | 73 |
| 2024 January | 78 | 3 | 81 |
| 2023 December | 69 | 3 | 72 |
| 2023 November | 99 | 3 | 102 |
| 2023 October | 119 | 7 | 126 |
| 2023 September | 80 | 1 | 81 |
| 2023 August | 72 | 6 | 78 |
| 2023 July | 73 | 4 | 77 |
| 2023 June | 63 | 3 | 66 |
| 2023 May | 98 | 4 | 102 |
| 2023 April | 87 | 2 | 89 |
| 2023 March | 86 | 0 | 86 |
| 2023 February | 90 | 4 | 94 |
| 2023 January | 75 | 11 | 86 |
| 2022 December | 60 | 6 | 66 |
| 2022 November | 81 | 2 | 83 |
| 2022 October | 79 | 8 | 87 |
| 2022 September | 45 | 7 | 52 |
| 2022 August | 42 | 8 | 50 |
| 2022 July | 44 | 12 | 56 |
| 2022 June | 34 | 6 | 40 |
| 2022 May | 30 | 8 | 38 |
| 2022 April | 37 | 10 | 47 |
| 2022 March | 63 | 8 | 71 |
| 2022 February | 40 | 7 | 47 |
| 2022 January | 54 | 2 | 56 |
| 2021 December | 35 | 22 | 57 |
| 2021 November | 36 | 12 | 48 |
| 2021 October | 47 | 14 | 61 |
| 2021 September | 41 | 20 | 61 |
| 2021 August | 34 | 7 | 41 |
| 2021 July | 31 | 10 | 41 |
| 2021 June | 19 | 5 | 24 |
| 2021 May | 34 | 13 | 47 |
| 2021 April | 58 | 12 | 70 |
| 2021 March | 31 | 13 | 44 |
| 2021 February | 12 | 5 | 17 |
| 2021 January | 6 | 10 | 16 |
| 2020 December | 13 | 11 | 24 |
| 2020 November | 10 | 2 | 12 |
| 2020 October | 5 | 2 | 7 |
| 2018 October | 1 | 0 | 1 |
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