Syphilitic Hepatitis: An Uncommon Manifestation of Secondary Syphilis

Syphilitic hepatitis is a rare manifestation of a sexually transmitted infection. Given its nonspecific presentation, it is important for clinicians to consider the diagnosis in sexually active patients presenting with elevated liver tests.  In this case, a 30-year-old man presented with an itchy rash and was diagnosed with an allergic reaction. He returned to the clinic one week later with a worsening rash. A sexual history was obtained, which led to sexually transmitted disease testing. Laboratory evaluation revealed a positive syphilis serology. A diagnosis of secondary syphilis was made, and he was treated with penicillin. The following day, he presented to the emergency department complaining of worsening rash, abdominal pain, and fever. Laboratory evaluation was significant for elevated transaminases. He received supportive care and was advised to follow up with his primary care provider. One month after his initial presentation, he presented to the clinic with resolution of the rash. Laboratory evaluation revealed a fourfold decrease in rapid plasma reagin titer and improvement in liver enzymes. The transaminitis work-up was unremarkable, and the liver tests ultimately normalized. A diagnosis of syphilitic hepatitis was made. A comprehensive detailed sexual history is important and key to the diagnosis of syphilitic hepatitis. Long-term sequelae are rare. Syphilitic hepatitis is a curable condition and should remain in the differential diagnosis in all sexually active persons presenting with abnormal liver enzymes.