Case Presentation: An otherwise healthy 31 years old Brazilian male presented to the hospital with two months history of constitutional symptoms, diffuse pruritic rash on torso and extremities, and diffuse lymphadenopathy. He lived with his wife and daughter, and most recent travel to Brazil was three months ago. His father has diabetes and mother died at age of 35 years from leukemia. On physical exam, bilateral postauricular, axillary and left inguinal non-tender lymphadenopathy was appreciated. A diffuse, blanching, nontender maculopapular rash was noted on the chest and abdomen. Liver profile showed elevated alkaline phosphatase 1100, ALT 253, and AST 112. Gamma Glutamyl Transferase (GGT) was elevated at 448 indicating a liver pathology. Extensive laboratory investigations including basic metabolic panel, complete blood count, coagulation profile, bilirubin, LDH, angiotensin converting enzyme, histoplasma antigens, and peripheral smear were normal. Viral testing for hepatitis, EBV, parvovirus, HIV, CMV, and Parvovirus were unremarkable. CT scan of the chest, abdomen and pelvis revealed a 2.2 cm spiculated nodule and 7 mm nodule in right lung as well as bilateral inguinal lymphadenopathy. Findings were concerning for malignancy. Surgical excision biopsy of the left inguinal lymph node and ultrasound guided liver biopsy were performed. Testing for Rapid Plasma Reagin (RPR) came back reactive with a titer of 1:64. Confirmatory FTA-ABS (fluorescent treponemal antibody absorption test) was positive. Furthermore, pathology of the excised lymph node was interpreted as Luetic or Syphilitic lymphadenitis. Spirochete immunostain was positive for organisms consistent with spirochetes. The liver biopsy revealed chronic active hepatitis and negative spirochete immunostaining.
Given constellation of physical findings and investigation results, a diagnosis of Secondary syphilis with lymphadenitis and hepatitis was made. After receiving intramuscular Benzathine Penicillin, he was seen at follow-up with resolved symptoms, decrement of RPR and marked improvement in liver enzymes. Patient later disclosed having an unprotected sexual intercourse with another woman during his trip to Brazil. A repeat CT chest for follow up of the lung nodules however our patient declined to pursue it.

Discussion: There have been very few reports in literature of secondary syphilitic hepatitis. Commonalities including generalized rash, marked elevation of alkaline phosphatase out of proportion to other liver enzyme abnormalities, serological evidence for syphilis, and improvement in liver enzymes with appropriate antimicrobial therapy. As treponemes have been inconsistently demonstrated in liver biopsies, it serves a greater role in excluding alternative diagnoses rather than confirming syphilitic hepatitis. The etiology of the pulmonary nodules is currently unclear as patient did not wish for further investigation. Syphilitic pulmonary lesions include infiltrates, solitary or multiple subpleural nodules, pleural effusion, or lymphadenopathy have been reported in just a few number of cases.

Conclusions: This case serves to remind practitioners of the characteristics and diagnostic evaluation of these sequela of syphilis. Increased awareness may obviate invasive and unnecessary testing.