Right Upper-Quadrant Pain in a Patient with Drug Abuse, Secondary Syphilis and Occult Hepatitis B Virus

Abstract

Objective: To describe the etiology of hepatitis and identify occult hepatitis B virus (HBV) infection. Clinical Presentation and Intervention: A 40-year-old man presented with severe abdominal pain and jaundice, a history of acute HBV infection that had cleared as well as the use of acetaminophen, methamphetamine, buprenorphine and marijuana. He admitted to having had unprotected sex with multiple partners of both genders. A thorough skin examination revealed papulosquamous lesions on his penis, scrotum, upper and lower extremities and feet. Transaminases and bilirubin were elevated. His rapid plasma reagin was reactive, and hepatitis serologies showed occult HBV. Liver biopsy showed severe hepatitis, but the stains for hepatitis B surface antigen and hepatitis B core antigen were negative. The pathological findings were highly indicative of drug-induced hepatitis without evidence of chronic hepatitis, reactivation of HBV or syphilitic hepatitis. With supportive management and abstinence from drugs, his condition improved. Conclusion: This case describes a patient with multiple potential causes for hepatitis and highlights the importance of obtaining a detailed social history. Further, one should consider the presence of occult HBV and recognize the serologic pattern.

A Systematic Literature Review of Syphilitic Hepatitis in Adults

“… 79 It is very difficult to identify the spirochetes in liver tissue among these patients. Only 19 patients showed spirochetes in the liver tissue on immunohistochemical staining 11 , 16 , 24 or Warthin–Starry staining. 43 , 51 , 52 …”

Secondary Syphilis With Hepatitis and Nephrotic Syndrome: A Rare Concurrence

“…Literature on syphilitic hepatitis, also known as luetic hepatitis, has been very sparse. Most of the patients are asymptomatic but in very rare instances present with right upper quadrant abdominal pain [ 4 ]. It is now recognized that in syphilitic hepatitis, there is an elevation of transaminases with or without cholestasis.…”

Hepatic Secondary Syphilis Can Cause a Variety of Histologic Patterns and May Be Negative for Treponeme Immunohistochemistry

“…9 Finally, 2 of our cases did not fit into any particular pattern based on overall histologic appearance. These demonstrated a constellation of various mild and/or nonspecific histologic patterns, and many examples of hepatic syphilis described in case reports appeared similarly nonspecific, 13,14,[16][17][18]30,31,33,37,42,43,[50][51][52][53][54][55][56][57] though in some instances this was due to limited provided histologic information. These nonspecific cases, as well as cases with a more defined pattern of injury, may include "supportive" findings seen in numerous cases in our study and others, which may help suggest the diagnosis of hepatic secondary syphilis but do not indicate a particular pattern of injury.…”

“…These nonspecific cases, as well as cases with a more defined pattern of injury, may include "supportive" findings seen in numerous cases in our study and others, which may help suggest the diagnosis of hepatic secondary syphilis but do not indicate a particular pattern of injury. These include prominent Kupffer cells (described in many studies in various patterns, 17,24,25,28,30,31,33,34,43,48,51,57 including 1 case with prominent sinusoidal histiocytes 39 ), poorly formed non-necrotizing granulomata 27,39,42,46,50,56,58 (which may rarely be the predominant finding 46 ), vessel wall inflammation, [25][26][27][28]39,51 sinusoidal inflammation, 9,28,29,39 and hepatic necrosis. 15,16,24,25,28,30,37,43,45,[49][50][51]54,55,57 Erythrophagocytosis is rarely mentioned.…”