Syphilitic Hepatitis: An Uncommon Manifestation of a Common Disease
Thirty nine years old male patient presented to medicine out patient department (OPD) with complaints of low grade fever, anorexia, malaise and pain in upper abdomen of one month duration along with dark coloured urine of 10 days duration. Patient gave history of consuming 40-50 grams of alcohol daily for past 3 years. There was no history of drug abuse or blood transfusion.\nExamination disclosed presence of icterus with normal vital signs. Per abdomen examination revealed 2 cm, firm, non tender hepatomegaly without splenomegaly or ascites.\nBiochemical analysis revealed increased values of serum bilirubin 3.5 mg/dl (normal 0.0-1.5 mg/dl), serum alanine transaminase (ALT) 357 IU/ml (normal < 50), serum aspartate transaminase (AST) 175 IU/ml (normal < 45) and serum alkaline phosphatase 536 IU/ml (normal 20-135). Screening for Hepatitis A, B, C and E were negative. Ultrasound abdomen revealed hepatomegaly with liver span of 16.4 cm with normal echotexture. Magnetic resonance cholangio pancreatography (MRCP) confirmed hepatomegaly with no space occupying lesion, lymphadenopathy or extra hepatic cholestasis.\nThe patient was thought to have acute hepatitis probably due to alcohol or non-hepatotropic viruses. Since the patient was showing clinical recovery with regression in serum bilirubin (1 mg/dl), AST (90 IU/ml) and ALT (152 IU/ml) though with rising alkaline phosphatase (711 IU/ml), Patient was asked to review after 1 month with the plan of performing liver biopsy after the resolution of acute phase.\nOn reporting back he presented to dermatology OPD with intensely itchy rash. Examination revealed multiple erythematous papules and plaques on neck, trunk, palms and soles [Figures –]. Buschke Olendroff sign was positive. There was bilateral, non tender, shotty inguinal lymphadenopathy, congestion of soft palate and posterior pharyngeal wall. Genital, per rectal, ophthalmic and auditory examination was normal.\nPatient gave history of repeated unprotected heterosexual intercourse with multiple partners during past two years. There were no symptoms suggestive of any sexually transmitted disease.\nA provisional diagnosis of secondary syphilis with syphilitic hepatitis was made. VDRL titre was 1:16 and TPHA was positive. Liver biopsy was suggestive of syphilitic hepatitis showing maintained hepatic architecture with Kupffer cell hyperplasia, lymphocytic and neutrophillic infiltration of portal tracts with mild neutrophillic infiltrate in hepatic lobules and no necrosis, granuloma, gumma or Treponema pallidum. Reticulin stain revealed early fibrosis around the portal tracts []. ELISA for HIV was negative. Positron emission tomography (PET) scan revealed hepatomegaly and presence of retroperitoneal, hilar, mediastinal, bilateral axillary, inguinal and external iliac lymph nodes. Patient was treated with 3 doses of intramuscular Benzathine Penicillin 2.4 million units, given weekly. He became asymptomatic with resolution of pruritus and mucocutaneous findings. There was normalization of serum bilirubin, ALT, AST values and reduction in alkaline phosphatase (383 IU/ml).