P2513 - The Hepatitis Enigma: Exploring a Rare Case of Syphilis-Associated Hepatitis

Syed Hamaad Rahman, DO, David S. Braun, MD, Armond G. Schwartz, MD
Methodist Dallas Medical Center, Dallas, TX

Introduction: Syphilis is a sexually transmitted disease caused by Treponema pallidum. Hepatitis is a rare presentation of syphilis, representing approximately 3% of all secondary infections. Patients typically present with disproportionately high serum alkaline phosphatase (ALP) and low-grade elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin. We present a case of syphilitic hepatitis to enlighten clinicians about this unusual presentation of an increasingly prevalent disease.

Case Description/Methods: An 18 year old female with no medical history was evaluated for a two-month history of right upper quadrant pain, jaundice and dark urine. She also complained of fatigue, myalgias, nausea, anorexia and a 20 lb weight loss. She reported unprotected sex one month prior to the onset of symptoms. Physical exam was notable for scleral icterus, right upper quadrant tenderness and inguinal lymphadenopathy. There was no rash noted. Liver function tests revealed elevated total bilirubin (2.7mg/dL), AST (528 U/L), ALT (313 U/L) and immeasurably high ALP ( >1,500 U/L). Liver ultrasound and computed tomography revealed no right upper quadrant abnormalities. Serology revealed reactive rapid plasma reagin (RPR) with a titer of 1:128, elevated anti-smooth muscle (46 IU) and anti-mitochondrial (93 U) antibodies. There was evidence of remote hepatitis A and Epstein-Barr virus. The patient was diagnosed with hepatitis due to secondary syphilis. She was treated with a single dose of 2.4 million units of intramuscular penicillin G which resulted in significant improvement in her symptoms within one week. Repeat liver function tests one month later showed a total bilirubin 0.8mg/dL, AST 34 IU/L, ALT 38 IU/L and ALP 240 IU/L. Six months later, liver function tests were normal and her anti-mitochondrial and anti-smooth muscle antibodies had normalized suggesting cross-reactivity. Repeat RPR titer one year later was 1:8.

Discussion: Syphilis is a rare cause of hepatitis with only an estimated 600 cases annually in the United States. Diagnostic criteria include abnormal liver enzymes in a cholestatic pattern, serologic evidence for syphilis, exclusion of other causes of liver disease and liver enzymes returning to normal after appropriate antibiotic therapy. Liver histopathology may show spirochetes in up to 50% of patients but is not required for diagnosis. This case highlights the diagnostic challenges associated with syphilitic hepatitis.


Disclosures:


Syed Hamaad Rahman, DO, David S. Braun, MD, Armond G. Schwartz, MD. P2513 - The Hepatitis Enigma: Exploring a Rare Case of Syphilis-Associated Hepatitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.