Maison Furley, MD, MS1, Violet Y. Tu, BA2, Chanjuan Shi, MD, PhD3, Lana Abusalem, MD1, Omar Martinez-Uribe, MD2, Thomas L. Holland, MD, MSc4, Raafat Sadeq, MD5 1Duke University Hospital, Durham, NC; 2Duke University, Durham, NC; 3Duke University Health System, Durham, NC; 4Duke University School of Medicine, Durham, NC; 5Duke University Medical Center, Durham, NC Introduction: Syphilitic hepatitis is a rare but increasingly recognized manifestation of Treponema pallidum infection, typically occurring during secondary syphilis. While most cases present with systemic symptoms and the pathognomonic maculopapular rash, isolated hepatic involvement is uncommon and often delays diagnosis.
Case Description/
Methods: A 33-year-old female presented with scleral icterus, fatigue, and markedly elevated aminotransferases (AST 1,426 U/L, ALT 2,524 U/L) and bilirubin (total 6.7 mg/dL). She did not have a fever, abdominal pain, or rash. Workup for viral, autoimmune, and metabolic hepatitis was unrevealing. Initial imaging was unremarkable. A syphilis screen was reactive with an RPR titer of 1:32. Liver biopsy revealed severe portal and lobular inflammation, bile duct injury, and positive immunohistochemical staining for spirochetes, confirming syphilitic hepatitis. She received intramuscular penicillin G, followed by corticosteroids due to delayed biochemical improvement. Liver enzymes normalized over several weeks. Discussion: This case highlights the diagnostic difficulty of syphilitic hepatitis when typical mucocutaneous signs are absent. Although classically cholestatic, this patient exhibited a hepatocellular injury pattern, further complicating diagnosis. Rising syphilis incidence in the U.S. underscores the importance of maintaining a broad differential for acute hepatitis. Early recognition and treatment are critical to prevent disease progression.
Figure: Prominent portal inflammation with lymphocytes, plasma cells, neutrophils, and eosinophils associated with bile duct injury.
Disclosures: Maison Furley indicated no relevant financial relationships. Violet Tu indicated no relevant financial relationships. Chanjuan Shi indicated no relevant financial relationships. Lana Abusalem indicated no relevant financial relationships. Omar Martinez-Uribe indicated no relevant financial relationships. Thomas Holland: Aridis – Consultant. Basilea – Consultant. Concert – Advisory Committee/Board Member. Karius – Consultant. Spero – DSMB Chair. Raafat Sadeq indicated no relevant financial relationships.
Maison Furley, MD, MS1, Violet Y. Tu, BA2, Chanjuan Shi, MD, PhD3, Lana Abusalem, MD1, Omar Martinez-Uribe, MD2, Thomas L. Holland, MD, MSc4, Raafat Sadeq, MD5. P1834 - Syphilitic Hepatitis Without Rash: A Diagnostic Challenge, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
