Introduction

Syphilis is a sexually or vertically transmitted disease caused by the spirochete T. pallidum. The liver involvement is very uncommon (< 1% of cases) and can occur in the 2º or 3º phase of the disease due to the multiplication and hematogenous spread of the spirochete to the liver. In the 2º syphilis phase, cholestasis occurs, with a typical elevation of alkaline phosphatase. Signs include pyrexia, the typical generalized rash involving the palms and the soles, and even nephrotic syndrome, not all required. In the tertiary phase, the characteristic lesions are syphilitic gummas, most commonly in the right lobe of the liver, and generally asymptomatic, but can cause compression leading to Budd–Chiari syndrome. Diagnosis includes blood tests like CBC, LFTs, blood cultures, and imaging such as sonography, CT scan, MRCP, ERCP, and percutaneous transhepatic cholangiography. Treatment includes IV antibiotics, ERCP, or surgery to open the duct and drain bile to reduce the build-up of fluid. This case study highlights the importance of detection of early syphilitic involvement of the bile duct and liver.

Case Description/Methods

A 53-year-old female with right-sided abdominal lower abdominal pain and occasional epigastric pain with bloating. She presented with maculopapular rash involving palms and soles with vague right-sided abdominal pain and left quadrant abdominal pain for 2 weeks duration associated with nausea. Treponema pallidum was found to be reactive. Colonoscopy revealed hyperplastic changes with focal lymphoid aggregate. As the patient was allergic to penicillin, doxycycline was started for 14 days.

Discussion

This case was unique as it shows the importance of keeping 2º/3º syphilis on the differential diagnosis of a patient presenting with cholestatic hepatitis. Treatment for syphilis results in the resolution of biochemical abnormalities. Syphilis as a cause of hepatitis was suspected based on the characteristic liver enzyme pattern, with more prominent elevation in the alkaline phosphatase level, negative serology for hepatotropic viruses, and the rapid resolution of symptoms and biochemical abnormalities with therapy. Given liver biopsy findings in syphilitic hepatitis, such as portal and lobular inflammatory cell infiltrates, hepatocellular necrosis, cholestasis, and non-caseating granulomas are non-specific and the identification of spirochetes is challenging, a liver biopsy is not crucial for diagnosing syphilitic hepatitis or cholangitis when therapy elicits a positive response.