Can syphilis affect the liver?

Syphilis Can Affect the Liver

Yes, syphilis can affect the liver, particularly during secondary and tertiary stages of infection, manifesting as syphilitic hepatitis or gummatous lesions. 1, 2

Liver Involvement in Different Stages of Syphilis

Secondary Syphilis

• Syphilitic hepatitis is a recognized but uncommon manifestation during the secondary stage of syphilis 1, 2
• Clinical presentation typically includes elevated liver enzymes with a characteristic pattern of disproportionately elevated alkaline phosphatase compared to transaminases 2
• Patients may present with fatigue, abdominal pain, and occasionally jaundice alongside other manifestations of secondary syphilis (rash, lymphadenopathy) 1
• Secondary syphilis involves virtually all organ systems, including potential liver involvement 3

Tertiary Syphilis

• In late (tertiary) syphilis, the liver can be affected by gummatous lesions 3
• The Centers for Disease Control and Prevention notes that tertiary syphilis can involve abdominal organs, including the liver 4
• Gummatous hepatic lesions can present as inflammatory masses that may be mistaken for malignant tumors 5

Diagnostic Considerations

• Diagnosis of syphilitic hepatitis requires:

  • Positive serologic tests for syphilis (both treponemal and non-treponemal) 4
  • Evidence of liver dysfunction (elevated liver enzymes, particularly alkaline phosphatase) 2
  • Exclusion of other causes of liver disease 6
  • Response to appropriate anti-syphilis treatment 2

• Liver biopsy may show:

  • Inflammatory infiltrates with neutrophils 5
  • Spindle cell proliferation 5
  • Granulomas and pericholangitis/cholangitis 5
  • Presence of Treponema pallidum organisms on immunohistochemical staining 7, 5

Special Populations

• HIV-infected individuals may have more apparent clinical manifestations of syphilis, including liver involvement 4, 5
• Men who have sex with men appear to have higher rates of syphilitic hepatitis based on case reports 7, 5
• Immunocompromised patients, such as transplant recipients, may develop liver dysfunction due to syphilis 7

Treatment and Prognosis

• The standard treatment for syphilitic hepatitis is the same as for the corresponding stage of syphilis:

  • For secondary syphilis: Benzathine penicillin G 2.4 million units IM in a single dose 4, 7
  • For late syphilis: Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM at 1-week intervals 4

• Liver function typically improves following appropriate antibiotic treatment 7, 2

• Failure to diagnose and treat syphilitic hepatitis promptly may result in substantial morbidity 1

Clinical Pearls and Pitfalls

• Syphilitic hepatitis should be considered in patients with unexplained liver enzyme elevations, particularly with disproportionate alkaline phosphatase elevation 2
• The diagnosis is often overlooked, leading to delayed treatment 2
• Concurrent HIV infection may modify the clinical presentation and accelerate progression of syphilitic disease, including hepatic involvement 3, 5
• Hepatic lesions due to syphilis may mimic malignancy on imaging studies 5
• Always consider syphilis in the differential diagnosis of liver dysfunction in patients with risk factors for sexually transmitted infections 1, 2