S5712 A Case of Syphilitic Hepatitis in a 21-Year-Old Man

Introduction: Syphilitic hepatitis is an uncommon form of liver injury that can progress to fulminant liver failure and cirrhosis if not timely recognized. We present a rare case of syphilitic hepatitis in a young male who presented with rectal bleeding. Case Description/Methods: A 21-year-old man was admitted with complaint of bleeding per rectum. History revealed high risk sexual behavior. Physical exam was negative for skin rashes. Colonoscopy showed multiple rectal ulcers and an anal fissure. Incidentally, blood work revealed markedly elevated Alkaline Phosphatase of 1,230 IU/L [normal: 52-128 IU/L], mildly elevated total bilirubin of 2.9 mg/dL [normal: 0-0.3 mg/dL], alanine aminotransferase 96 IU/L [normal: 5-40 IU/L] and aspartate aminotransferase 73 IU/L [normal: 9-48 IU/L] levels. HIV, HBV and HCV serology tests were negative. Abdominal Ultrasonography was negative for choledocholithiasis. Liver biopsy showed a liver parenchyma with mild to moderate mixed portal inflammation, focal ductular reaction and edema but with no significant cholestasis or fibrosis. Nontreponemal testing for syphilis returned positive with an RPR titer of 1:64 and a positive treponemal (Treponema Pallidum Particle Agglutination) test assay. Patient was treated with 2.4 million units of intramuscular benzathine penicillin weekly for 3 weeks. Patient had complete resolution of liver chemistry abnormalities following the treatment course. Discussion: Syphilis is a sexually and vertically transmitted disease caused by the bacteria Treponema pallidum. Syphilis can cause severe complications involving multiple organ systems if not timely detected and treated. Diagnosis is often challenging as the symptoms differ during the 3 disease stages and can mimic multiple other ailments. Syphilitic hepatitis typically presents with a cholestatic pattern of liver test abnormalities, usually in the second stage of the infection spectrum. Timely diagnosis of syphilitic hepatitis is essential in definitive treatment and preventing progression to fatal fulminant liver failure, irreversible liver cirrhosis and other late stage complications.