Early syphilitic hepatitis concomitant with nephrotic syndrome followed by acute kidney injury

Abstract

Although acute hepatitis and nephrotic syndrome are commonly reported as complications of tertiary syphilis, nephrotic syndrome concomitant with hepatitis in early-stage syphilis is rare. Here, we describe the case of a 46-year-old male who was diagnosed with acute liver dysfunction and nephrotic syndrome after presenting with general malaise, and who subsequently developed acute kidney injury. Laboratory examination showed alkaline phosphatase had a greater magnitude of elevation compared to alanine aminotransferase, suggesting the possibility of syphilitic hepatitis. The rapid plasmin regain test and Treponema pallidum hemagglutination assay were positive, supporting the presence of a syphilis infection. Additionally, liver biopsy examination showed infiltration of inflammatory cells into the portal area and epithelioid cell granulomas. Moreover, kidney biopsy examination by both optical and electron microscopy showed a congestion of neutrophils in the capillary vessels, structural collapse of the tubules, and subepithelial deposits under the epithelium of the glomerular endothelial cells. These pathological changes were consistent with those reported previously for early syphilitic hepatitis and nephrotic syndrome in early-stage syphilis. All the symptoms, including liver and renal dysfunction, resolved after benzyl penicillin treatment was initiated. Hence, we believe early-stage syphilis should be included in the differential diagnosis of unknown liver damage and/or nephrosis.

Renal manifestations of syphilis

“…1 Membranous nephropathy: this was the most commonly reported renal lesion associated with syphilis with a wide age range affected from 18 to 71 years of age. [10][11][12][13][14][15][16][17][18][19][20][21][22] Patients generally presented with acute onset nephrotic syndrome, and less frequently with other features like a maculopapular rash, mucocutaneous lesions, hepatitis and lymphadenopathy. 10,11,13,19 All reported cases demonstrated on renal biopsy, a thickened glomerular basement membrane without features of a proliferative glomerulonephritis.…”

“…Syphilis affecting the kidneys is rare but a well described manifestation of secondary syphilis with the prevalence ranging from 0.3% to 10% of patients diagnosed with secondary syphils 9 . We describe below the range of renal manifestation with syphilis. Membranous nephropathy: this was the most commonly reported renal lesion associated with syphilis with a wide age range affected from 18 to 71 years of age 10–22 . Patients generally presented with acute onset nephrotic syndrome, and less frequently with other features like a maculopapular rash, mucocutaneous lesions, hepatitis and lymphadenopathy 10,11,13,19 .…”

The wrong Spirochaete? Acute kidney injury in a returning traveller with syphilis – a case report

“…One case (2014) of AKI describes a 46-year old man with nephrotic syndrome and hepatitis in early syphilis [ 10 ]. Another describes syphilitic nephropathy, both with significant proteinuria, in two patients with HIV co-infection [ 11 ].…”

Liver and Bile Duct Infections

“…11.25). 310,317,318 Rarely, other patterns can be seen, such as diffuse sinusoidal histiocytic infiltration or postinfantile giant cell hepatitis. 319 Spirochetes are only rarely identified in histologic sections with silver stains, such as Warthin-Starry or Steiner.…”

“…[299][300][301][302][303][304] A characteristic clinical picture is cholestatic jaundice, hepatomegaly, and a disproportionately elevated alkaline phosphatase level. 305,307,308,[310][311][312][313] The trademark palmar rash of syphilis may be the key to diagnosis. 298…”