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Symptomatic syphilitic hepatitis is relatively uncommon, and is difficult to diagnose without a high clinical suspicion. This case highlights the importance of maintaining a high degree of clinical suspicion and the use of doxycycline as an effective alternative therapy.
Case Description:
The patient is a previously healthy 28 year old male with fatigue, nausea and vomiting several days prior to development of painless jaundice. He reported rare acetaminophen use and alcohol consumption but denied injection drug use. He report approximately 30 sexual partners in the last year, with 12 new partners in the preceding 3 months. Serious penicillin allergy was reported. Examination revealed icteric sclera, and a diffuse maculopapular rash including palms and soles. Laboratory test results included elevated transaminases (ALT=1475 IU/L, AST= 825 IU/L) and total bilirubin (9.5 mg/dl). Serologic tests for Hepatitis A, B, C, and E were negative, as were tests for HIV, herpes simplex, cytomegalovirus, ceruloplasmin, and acetaminophen. Treponemal IgG was positive with a RPR of 1:128. Transaminases peaked at ALT=1605 IU/L, AST=968 IU/L, and total bilirubin at 14.2 mg/dl. Liver biopsy documented severe, acute hepatitis. Treatment for secondary syphilis was initiated with doxycycline 100 mg twice daily for 14 days. Within 3 weeks of treatment completion, icterus, jaundice, and rash completely resolved, with return to normal levels of transaminases and bilirubin.
Discussion:
The incidence of syphilitic hepatitis is unknown, although perhaps 50% of patients with secondary syphilis have subclinical transaminase elevations. This patient was notable in his initial presentation with jaundice, evidence of secondary syphilis, and penicillin allergy. Relatively few recent reports address treatment of syphilitic hepatitis, particularly when penicillin is contraindicated. This patient showed rapid response to oral doxycycline, suggesting this as an effective alternative when necessary.