Karthic Drishna Perumal, MD1, Omar Brijawi, MD2, Matthew Holcomb, DO3 1Mount Carmel Health System, Powell, OH; 2Mount Carmel Health System, Grove City, OH; 3Mount Carmel Health System, Columbus, OH
Introduction:
Syphilitic hepatitis (SH) is a rare and often misdiagnosed condition in patients with abnormal liver function tests. It can be defined by a cholestatic pattern of transaminase elevation with serological treponemal evidence in the absence of other causes of hepatic injury. Most patients usually recover with a single injection of Benzathine penicillin G, but some may not tolerate this treatment due to severe allergies to penicillin. We have investigated a case of syphilitic hepatitis amendable to alternative treatment strategies.
Case Description/Methods:
A 43-year-old Caucasian female with a past medical history of ectopic pregnancy status post hysterectomy, appendectomy, and chronic constipation presented to the emergency department for worsening abdominal pain and fever. She reported symptoms of night sweats, fevers up to 101-102.4 °F, worsening nausea, decreased appetite, and lightheadedness. Physical exam revealed a diffuse, macular, pruritic rash on the torso and extremities including the palms and soles; tenderness over the right upper and left lower quadrants; and bilateral tender inguinal lymph nodes, approximately 3 cm in size. Labs showed a cholestatic pattern of liver injury, positive treponema palladium antibody, and rapid plasma reagin (RPR) quantitative study of 1:128. Abdominal imaging did not reveal any acute hepatobiliary pathology. Due to severe allergic reactions to penicillin, an infectious disease consult recommended starting doxycycline 100 mg twice daily for 14 days. The patient's symptoms on admission had reduced by the end of her stay and repeat outpatient quantitative RPR demonstrated a 16-fold decrease (1:8), ALP at 133, and near normalization of aminotransferases as well.
Discussion: Our patient presented with a cholestatic pattern of liver injury. Her workup revealed negative viral hepatitis serologies and other infectious workups, non-acute liver ultrasound, and CT imaging, but through positive treponema palladium antibody and RPR values, we arrived at our diagnosis of syphilitic hepatitis. Our patient also had a history of severe penicillin allergy. Thus, our patient underwent an unorthodox treatment strategy with doxycycline. SH should be considered an important differential when working up a cholestatic pattern of liver injury that is not the result of any acute biliary pathology. Penicillin remains the mainstay treatment for all stages of syphilis, but patients who experience severe drug reactions to penicillins can undergo alternative treatment with doxycycline.
Note: The table for this abstract can be viewed in the ePoster Gallery section of the ACG 2024 ePoster Site or in The American Journal of Gastroenterology's abstract supplement issue, both of which will be available starting October 27, 2024.
Disclosures:
Karthic Drishna Perumal indicated no relevant financial relationships.
Omar Brijawi indicated no relevant financial relationships.
Matthew Holcomb indicated no relevant financial relationships.
Karthic Drishna Perumal, MD1, Omar Brijawi, MD2, Matthew Holcomb, DO3. P4776 - POSTER WITHDRAWN, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
