Two cases of hepatic lues demonstrating the highly variable presentation of syphilis

Lues is an important differential diagnosis in patients with aetiologically unclear hepatitis or liver lesions. Lues can present with a plethora of symptoms and organ-systems involved, leading to diagnostic obstacles. Syphilitic hepatitis can occur at any stage of lues. We present a case of severe syphilitic hepatitis and another case of hepatic gummas with hepatitis.

Patient 1: A 44-year-old man with HIV and previously treated Lues-infection was admitted with liver lesions (max. 2.8 cm) and cholestatic hepatitis (AP 276 U/l, ALT 88 U/l). The initial suspected diagnosis was lymphoma, whereupon a liver biopsy was performed. Histology revealed giant cell granuloma, serology showed no evidence of viral hepatitis/AIH. Cardiolipin-Microflocculation-Test (CMT) was positive (1:256). Ten days of intravenous ceftriaxone treatment led to normalization of transaminases/cholestatic parameters. Ultrasound examination showed a complete remission of the liver lesions and a decrease in CMT values (1:16, six months after treatment).

Patient 2: A 21-year-old man was admitted with jaundice (bilirubin 10.7mg/dl) and hepatitis (ALT 1300U/l). He reported sexual contact with men and the physical examination revealed perianal eczema. Viral hepatitis and HIV were negative, ANA 1:80, and CMT was positive (1:128). Treatment with ceftriaxone (penicillin allergy) followed, liver biopsy revealed severe hepatitis compatible with syphilitic hepatitis DD AIH. Due to progressively elevated bilirubin, short-term prednisolone treatment followed, which led to a rapid improvement. Follow-up examinations showed complete remission even after discontinuation of prednisolone three months after discharge.

Conclusion: Lues can present with hepatitis and hepatic gummas and should be included in differential diagnosis.

Publication History

Article published online:
20 January 2025