Syphilitic Hepatitis: A Case Report of Secondary Syphilis Presenting as Cholestatic Liver Injury

Syphilitic Hepatitis Diagnosed in a 61-Year-Old Man Presenting With Cholestatic Liver Injury

Syphilitic hepatitis is a rare and frequently overlooked manifestation of a sexually transmitted infection that can cause a cholestatic pattern of liver injury. The condition occurs when Treponema pallidum, the spirochete responsible for syphilis, spreads to the liver during systemic dissemination. While overall rates of syphilis have climbed globally—with the World Health Organization estimating 8.0 million new infections among adults aged 15 to 49 in 2022 compared to 7.1 million in 2020—hepatic involvement remains an uncommon clinical presentation that mimics other forms of liver disease.

Clinical Presentation and Laboratory Findings of Syphilitic Hepatitis

Physical examination revealed jaundice, anterior cervical lymphadenopathy, and erythematous macular lesions on his trunk and limbs that notably spared his palms and soles. Laboratory results showed a distinct cholestatic injury pattern: alkaline phosphatase reached 895 U/L and gamma-glutamyl transpeptidase hit 981 U/L, while alanine aminotransferase and aspartate aminotransferase were mildly elevated at 103 U/L and 84 U/L, respectively. His total bilirubin stood at 3.16 mg/dL. Comprehensive panels for viral hepatitis, human immunodeficiency virus, and autoimmune markers returned negative results. The Venereal Disease Research Laboratory test proved reactive, and anti-Treponema pallidum IgG was positive, confirming secondary syphilis with hepatic involvement.

Treatment Outcomes and Comparison With Similar Cases

Following the diagnosis of secondary syphilis with hepatic involvement, the patient received treatment, in accordance with standard international guidelines. Over the following six months, his clinical symptoms resolved, and his liver biochemical parameters largely returned to normal limits. The presentation contrasts with other documented cases of syphilitic hepatitis.

Frequently Asked Questions About Syphilitic Hepatitis

What is syphilitic hepatitis?

Syphilitic hepatitis is an uncommon hepatic manifestation of Treponema pallidum infection characterized by disproportionately elevated cholestatic liver enzymes, such as alkaline phosphatase and gamma-glutamyl transpeptidase, relative to standard transaminases.

How is syphilitic hepatitis diagnosed?

Diagnosis relies on combining a reactive non-treponemal serologic test—such as the Venereal Disease Research Laboratory test or rapid plasma reagin—with a positive treponemal-specific assay, alongside the exclusion of viral, autoimmune, and drug-induced liver injuries.

What is the standard treatment for secondary syphilis involving the liver?

International guidelines recommend a single intramuscular dose of benzathine penicillin G, which typically resolves both systemic symptoms and liver biochemical abnormalities.

Why is syphilitic hepatitis frequently missed by clinicians?

Because presenting symptoms like fatigue, jaundice, and weight loss are non-specific and mimic biliary obstruction or drug-induced liver injury, clinicians often evaluate for common hepatotropic viruses before considering a sexually transmitted infection.

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