The Great Impostor: Transaminitis Masking the Coinfection of Syphilis and Human Immunodeficiency Virus

Abstract

Introduction. The incidence of syphilis continues to rise in the United States over the past 15 years. This disease process is classified into stages and may present with a coinfection of Human Immunodeficiency Virus (HIV). Case Report. We present a case of a 32-year-old African American male who presented with cutaneous manifestations of secondary syphilis and transaminitis. A workup revealed that the transaminitis was secondary to underlying syphilitic hepatitis in the presence of HIV coinfection. The patient had a reactive rapid plasma reagin (RPR) of 1 : 64 TU and reactive Treponema pallidum particle agglutination assay (TPPA). Lab findings showed alkaline phosphate (ALP) of 648 unit/L, aspartate aminotransferase (AST) of 251 unit/L, and alanine aminotransferase (ALT) of 409 unit/L. Conclusion. Syphilitic hepatitis is a recognized entity in the medical literature. It is a manifestation of secondary syphilis and it is more commonly seen in coinfected patients with both syphilis and HIV. Therefore, primary care physicians should keep infectious etiologies (e.g., syphilis and HIV) in the differential diagnosis of patients who present with unexplained liver dysfunction in a cholestatic pattern.

Syphilitic Hepatitis: A Rare Cause of Acute Liver Injury

“…The most common stage that causes abnormal liver enzymes is secondary syphilis. It is estimated that 3% of secondary syphilis cases can present as syphilitic hepatitis, but among all the patients with syphilis, hepatitis occurs in 0.2% to 3% of patients [3,4]. A literature review of 97 cases by Huang et al in 2018 demonstrated that the most common clinical manifestations of syphilitic hepatitis were rash (78%), fatigue/poor appetite (57%), icterus (35%), fever (26%), weight loss (23%), abdominal pain (22%), phallodynia (13.4%), sore throat (8.2%), and headache 7.2%.…”

Spirochetes in the Liver: An Unusual Presentation of a Common STI

“…The first recognized case of hepatitis attributable to syphilis was reported in 1585 and termed “luetic jaundice” [4]. While syphilitic hepatitis has since been an established diagnosis in the medical literature as a component of secondary syphilis, it is not a commonly encountered etiology in patients seen for transaminitis, much less clinical hepatitis [5].…”

“…Liver involvement in secondary syphilis is especially prevalent in patients with concurrent HIV infection, likely due to similar risk factors and degree of immunosuppression [2, 8]. The notable high rates of coinfection can be attributed to parallel risk factors including unprotected sexual activity, men who have sex with men, and intravenous drug use [4]. The most current CDC STD treatment guidelines emphasize the importance of routine HIV screening in all patients who pursue evaluation and therapy for any STDs [9].…”

“…When secondary syphilis signs recede, the patient enters the latent phase in which serologies remain positive without any overt signs or symptoms of infection. Tertiary syphilis may develop in about one-third of those with latent disease, presenting as neurosyphilis, aortic root insufficiency, or gummatous lesions [1, 4]. Overall, tertiary syphilis is scarce in our postantibiotic era.…”

Hepatitis sifilítica: reporte de una serie de casos

“…La afectación hepática es un compromiso poco habitual de la sífilis primaria y secundaria, descrita en aproximadamente 0,2-3%, siendo más frecuente en pacientes VIH, ya que comparten factores de riesgo similares 5,6 .…”