SHM Converge Scientific Abstract ePoster Gallery-The Great Imitator: Syphilis Hepatitis and Possible Pancreatitis

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This case describes a 49-year-old man who presented with persistent abdominal discomfort, diffuse rash, night sweats, arthralgias, and a penile ulcer after recent hospitalization elsewhere for presumed “gallstone pancreatitis” and hepatitis. Surgery was deferred because of abnormal liver enzymes. On exam, he was hemodynamically stable, had a benign abdominal exam, a macular rash consistent with secondary syphilis, and a genital ulcerative lesion. His sexual history revealed recent unprotected sex.<br /><br />Laboratory evaluation showed a markedly cholestatic liver injury pattern with peak AST 399, ALT 453, alkaline phosphatase 1,015, total bilirubin 1.5, and mildly elevated lipase of 97. Workup for other causes of hepatitis was negative, including acute viral hepatitis, IgG4-related disease, ceruloplasmin, alpha-1 antitrypsin deficiency, LKM antibody, ANA, AMA, and ASMA. Serologies were strongly positive for syphilis (RPR 1:256 and treponemal antibody). Imaging showed an edematous, diffusely thickened pancreas, raising concern for pancreatitis.<br /><br />The presentation was most consistent with syphilitic hepatitis, a rare manifestation of secondary syphilis that classically causes cholestatic rather than hepatocellular injury. The rapid improvement in liver tests after penicillin treatment supported the diagnosis and helped avoid invasive liver biopsy and a potentially unnecessary cholecystectomy for presumed gallstone pancreatitis. Although syphilis has rarely been reported to involve the pancreas, true pancreatitis remains uncommon.<br /><br />This case highlights syphilis as an important and underrecognized cause of abnormal liver enzymes and possible pancreatic involvement. It emphasizes the value of obtaining a sexual history in patients with unexplained hepatitis and abdominal pain, and serves as a reminder to consider “the great imitator” in atypical hepatobiliary presentations.

Asset Subtitle

Andrew Para

Meta Tag

Author List Andrew Para, Khadeja Khan, Sara Patino

Category Clinical Vignettes

Concept Syphilitic Hepatitis

Concept Abnormal Laboratory Tests

Concept Cholestatic Pattern

Concept Secondary Syphilis

Concept Alkaline Phosphatase

Distinguished Non-Finalist

Presenter Organization University of Miami

Presenting Author Andrew Para

Track Adult

Keywords

syphilitic hepatitis

secondary syphilis

cholestatic liver injury

penile ulcer

diffuse rash

abdominal pain

pancreatitis

penicillin treatment

unprotected sex

abnormal liver enzymes

Syphilitic Hepatitis

Abnormal Laboratory Tests

Cholestatic Pattern

Secondary Syphilis

Alkaline Phosphatase