The Great Pretender: early syphilis mimicking acute sclerosing cholangitis

Abstract

A 36-year old man with known HIV infection presented to an outpatient genitourinary service with jaundice, rash and sore throat. Investigations revealed marked biochemical abnormalities, including alkaline phosphatase and alanine transaminase >10 times the upper limit of normal. Liver ultrasound was normal, but stricturing and beading of the intrahepatic biliary tree was seen on magnetic resonance cholangiopancreatography (MRCP), similar to changes associated with sclerosing cholangitis. Serological syphilis antibodies were detected with a positive immunoglobulin M (IgM) and rapid plasma reagin of 1:128, in keeping with early infection. Liver biopsy showed large bile duct obstruction with portal oedema, bilirubinostasis and neutrophil polymorph infiltration around proliferating ductules; specific stains for spirochaetes were negative. Symptoms and biochemical markers improved rapidly after treatment for secondary syphilis with oral steroids and intramuscular benzathine penicillin. A repeat MRCP 18 months post syphilis treatment showed resolution. This case illustrates syphilis presenting as acute sclerosing cholangitis.

Cholangitis and pulmonary nodules in a clinical presentation of syphilis in an HIV-infected patient

“…4 To the best of our knowledge, only one case of cholangitis confirmed with magnetic resonance cholangiography in a HIV-infected patient has been published. 5 Similar to our patient, this case had bile duct involvement but did not have pulmonary involvement.…”

Clinics in diagnostic imaging (219)

“…Hepatobiliary involvement in syphilis is not common, with only two other known reported cases of secondary syphilis with sclerosing cholangitis and 144 cases of syphilitic hepatitis reported in a systematic review by Huang et al . [ 2 3 4 ] Syphilitic hepatitis has a similar clinical presentation — a characteristic rash and deranged liver function tests with a predominantly cholestatic picture. Histopathological features include inflammatory cell infiltration of portal areas or hepatic lobules, hepatocellular necrosis and cholestasis.…”

Gastrointestinal bleeding caused by syphilis: A case report

“…In recent years, some rare cases of syphilis infection with formation of colorectal inflammatory masses that caused gastrointestinal bleeding[ 2 ], and cranial nerve infection that caused neurological disease[ 12 ] have been reported. There have been cases associated with hepatitis, sclerosing cholangitis, pancreatitis, unilateral nipple bleeding, papillary edema, venous congestion, obstruction, intracranial hemorrhage, cerebral infarction, and other systemic diseases[ 13 - 17 ]. This patient was diagnosed with syphilis in 2008 and failed to receive treatment many times.…”